Signature Healthcare Of Roanoke Rapids
Inspection history, citations, penalties and survey trends for this long-term care facility in Roanoke Rapids, North Carolina.
- Location
- 305 East Fourteenth Street, Roanoke Rapids, North Carolina 27870
- CMS Provider Number
- 345336
- Inspections on file
- 29
- Latest survey
- March 26, 2026
- Citations (last 12 mo.)
- 7
Citation history
Health deficiencies cited at Signature Healthcare Of Roanoke Rapids during CMS and state inspections, most recent first.
The facility failed to accurately document and reconcile controlled medications for multiple residents, including those receiving hydrocodone-acetaminophen, oxycodone, and Oxycontin for pain. For one resident with metastatic cancer and severe pain, controlled drug records showed more doses removed from locked storage than were documented as administered on the MAR, and several nurses admitted to forgetting MAR documentation, misdating removals, or signing out doses without times to correct off-counts. On one unit, the controlled substance count sheets over several days lacked required dual signatures, omitted counts of cards and sheets, and contained undocumented additions and subtractions of medication cards, with some shifts showing no recorded reconciliation at all. For another resident on chronic Oxycontin, the pharmacy’s dispense and return records did not match the facility’s controlled drug records, and neither the pharmacist nor the corporate nurse consultant could reconcile the discrepancies. A third resident on scheduled Oxycontin and PRN oxycodone had MAR entries indicating doses were given without corresponding removals on the controlled drug record, and nurses later reported holding doses without correcting the MAR, giving PRN oxycodone instead of scheduled Oxycontin without clear documentation, or being unable to explain mismatched records.
The facility failed to maintain accurate and complete medical records for two residents, including documentation of bowel movements and administration of controlled pain medications. One resident with advanced cancer had bowel movements under-documented despite staff acknowledging more frequent occurrences, and multiple doses of hydrocodone-acetaminophen and oxycodone were signed out on the controlled drug record without corresponding entries on the MAR, even though nurses stated the medications were given. Another resident with vertebral osteomyelitis and chronic low back pain had a scheduled Oxycontin dose documented as administered when it was actually held due to sedation, and the nurse involved did not know how to correct the electronic MAR. The DON and interim Administrator both acknowledged that these records were incomplete or inaccurate.
A resident with Stage IV cancer and Stage IV kidney disease was admitted from the hospital with a discharge summary listing multiple scheduled follow-up appointments, including a PET scan and oncology and nephrology visits. The facility’s process required nursing staff to review the discharge summary and provide it to the Transportation Nurse Aide to arrange transport, but this did not occur. The family member went to the oncology appointment expecting to meet the resident, believing transportation had been arranged, but the resident never arrived and all appointments were missed. The Transportation Nurse Aide and Social Worker reported they were unaware of the appointments, and the DON confirmed the discharge summary had not been given to the Transportation Nurse Aide as expected.
A resident with metastatic cancer, an open malignant shoulder wound, neuropathy, and a history of spine surgery had PRN hydrocodone, PRN oxycodone, and scheduled gabapentin ordered for pain and was care-planned to request and receive pain meds as needed. On one evening shift, the resident requested pain medication early in the shift, but the assigned nurse did not administer any opioid analgesic, could not be located by the NA, and was later found asleep in a car with the med cart keys. Another nurse, working on a different unit, and other staff repeatedly attempted to wake the assigned nurse and contacted the DON, but the resident’s first documented oxycodone dose on that shift was not given until the early morning hours, at which time the resident was tearful and reported extreme pain. The MAR showed no hydrocodone given that shift and no documented time for the evening gabapentin dose, demonstrating a significant delay in providing ordered pain management.
A resident with multiple comorbidities and severely impaired cognition experienced two falls in one day. After the second fall, an RN assessed new left leg pain and obtained a STAT order for x‑rays of the left hip and femur, but the mobile x‑ray was not completed that night due to access issues and lack of staff response. The next morning, the resident’s representative reported the resident was in pain and requested Tylenol before dialysis; an RN performed a limited assessment, relied on the prior evaluation and pending STAT x‑ray, and allowed the resident to attend dialysis, while the DON, seeing the resident laughing in a wheelchair, did not assess pain. When the x‑ray technician arrived later, the resident was already at dialysis, and the exam was again delayed. Dialysis documentation showed ongoing left lower extremity pain and early termination of treatment, and the resident was later found to have a hip fracture requiring surgery. The deficiency centers on the failure to ensure timely completion of the ordered STAT x‑ray and prompt diagnostic evaluation of the resident’s post‑fall leg pain.
Surveyors identified significant medication errors involving two residents who did not receive scheduled rapid-acting insulin doses due to a staffing shortage, and another resident who continued to receive prednisone despite a pulmonologist's recommendation to discontinue it. The errors were linked to missed medication administration, lack of timely communication, and failure to implement consultation recommendations.
Due to insufficient nursing staff coverage, two residents with diabetes did not receive their scheduled morning doses of rapid-acting insulin. The absence of a medication aide and a unit manager resulted in delayed medication administration, and communication lapses among staff further contributed to the missed doses. The incident was confirmed through medication records and staff interviews.
A resident with hemiplegia and transfer dependence was manually transferred from a wheelchair to bed by an agency CNA without the required mechanical lift, despite clear care plan instructions and available assistance. The resident reported being handled roughly and experienced severe pain, later found to be due to a comminuted, displaced femur fracture. Staff interviews and documentation confirmed the transfer was not performed per protocol.
The facility did not update its facility-wide assessment to reflect the needs of all residents, including two who required tracheostomy care. The assessment inaccurately stated no residents needed such care, and the Administrator admitted to not reviewing the assessment in the previous year.
The facility failed to accurately code MDS assessments for several residents, leading to discrepancies in medical records. A resident with improved kidney function was incorrectly coded for dialysis, another with vascular dementia was not coded for a wander guard alarm, and a diabetic resident was not coded for hypoglycemic medication. Additionally, a resident dependent on dialysis was not correctly coded upon readmission. The MDS Nurse was responsible for these inaccuracies.
The facility failed to properly label and store medications, with an insulin pen and albuterol inhaler found unlabeled on Unit 3, and a netarsudil solution unrefrigerated on Unit 1. Additionally, a wound treatment cart on Unit 3 was left unattended and unlocked, containing resident treatment supplies. The DON confirmed that all staff were responsible for ensuring proper labeling, storage, and security of medications and treatment carts.
The facility failed to maintain sanitary conditions in the kitchen, with observations revealing unclean equipment such as a plate dispenser with dried food particles and a steam table shelf covered in food debris. Despite having a cleaning schedule, these areas were overlooked, as confirmed by the dietary managers and the Administrator.
The facility failed to properly dispose of garbage in the dumpster area, with observations of an open dumpster lid, scattered litter, and uncollected waste. The Dietary District Manager noted the area was cleaned earlier, but the waste company did not pick up dropped items. The Administrator stated all staff were responsible for maintaining cleanliness, and the Corporate Administrator suggested daily inspections.
A facility failed to complete a Minimum Data Set (MDS) Significant Change in Status Assessment for a resident who was admitted with a diagnosis of malignant neoplasm and later admitted to hospice. Despite a physician order indicating the resident's terminal status and hospice admission, no MDS assessment was completed to reflect this change. Interviews with the MDS Nurse and Administrator confirmed the oversight.
A resident with severe cognitive impairment and specific activity preferences did not have a person-centered care plan developed by the facility. Despite expressing interest in activities like reading and music, the resident's care plan lacked these provisions. Observations showed the resident often in their room with the TV on, and interviews revealed confusion among staff about responsibility for care plan development.
A facility failed to obtain a physician order for tracheostomy care for a resident with a tracheostomy. Although nursing staff provided care, including cleaning and suctioning, there was no documented physician order for tracheostomy site care. The Unit Manager acknowledged the oversight, and the DON could not explain how the order was missed.
A facility failed to ensure a resident receiving dialysis had a physician's order for the service. The resident, dependent on renal dialysis, was readmitted from the hospital without the dialysis order being reinstated. Staff interviews confirmed the oversight, with the Unit Manager and DON acknowledging the failure to reestablish the order. The Administrator also noted that staff should have ensured the presence of a physician's order.
The facility failed to notify the Ombudsman of hospital transfers for two residents. The Social Service Director was running incorrect reports, leading to missed notifications. Interviews revealed that the Director of Nursing and interim Administrator were unaware of the issue, which was identified through record reviews and staff interviews.
Failure to Accurately Document and Reconcile Controlled Medications
Penalty
Summary
The deficiency involves the facility’s failure to accurately document and reconcile controlled medications for multiple residents, and to follow its system for accounting for controlled substances between shift changes and upon receipt or removal from locked storage. For one resident with metastatic cancer, open malignant wound, neuropathy, and a history of spine surgery, hydrocodone-acetaminophen and oxycodone orders were in place for pain management. The hydrocodone-acetaminophen controlled drug record showed 11 removals from storage, while the MAR reflected only one administered dose. The oxycodone controlled drug record showed 13 removals, while the MAR reflected 11 administered doses. Several nurses signed out controlled medications without corresponding MAR documentation, left times blank, or misdated removals. One nurse reported he arrived late for his shift, did not believe a narcotic count was done at shift change, and later signed out additional doses without times to correct an off count, intending another nurse to fill in the times. Another nurse admitted she often became busy and forgot to document administrations on the MAR after removing doses from storage, and another nurse stated she administered a dose but forgot to sign the MAR. The facility’s unit-level controlled substance count sheets also showed multiple deficiencies in reconciliation practices. On one unit, over a period of several days, the controlled substance count sheet documented 20 instances where medication cards were added to or subtracted from the total count. For 11 of these, only one nurse’s signature was present, and for seven there were no nurse signatures at all. In two instances, there was only a notation of “+1” without any information about which medication, which resident, or which nurse was involved. Across multiple days and shifts, required signatures of off-going or on-coming nurses were missing, the number of cards/containers and count sheets was left blank, and there were gaps of up to 36 hours with no documented count or reconciliation. The DON later reported that a count had been reconciled in her presence during one of these undocumented periods, but this reconciliation was not reflected on the count sheet. For another resident with chronic pain receiving Oxycontin twice daily, discrepancies existed between the pharmacy’s records and the facility’s records regarding dispensed and returned doses. The pharmacy’s system showed that 28 Oxycontin tablets were dispensed on one date, that 17 doses from that fill were returned the following day, and that another 28 tablets were sent on the same day as the recorded return. The pharmacist stated they had no record of returned Oxycontin from the later dispense and were still awaiting unused doses. In contrast, the facility’s controlled drug records showed all 28 doses from the first fill were used with none returned, and that 17 doses from the second fill remained after discharge and were returned on a later date. The Corporate Nurse Consultant stated that the facility’s return documentation was pulled directly from the pharmacy’s system and could not explain why the pharmacy’s internal records and the facility’s records could not be reconciled. A third resident with vertebral osteomyelitis and low back pain had orders for scheduled Oxycontin and PRN oxycodone. For this resident, the March MAR and Oxycontin controlled drug record did not consistently match. On one date, a nurse initialed the 10:00 AM Oxycontin dose as given on the MAR, but no corresponding removal was documented on the controlled drug record; the nurse later stated she had not administered the dose because the resident appeared sedated, and that she had signed the MAR before deciding to hold the dose and did not know how to correct the entry. On another date, a nurse documented administration of PRN oxycodone and placed initials with an asterisk and the comment “RC” by the 10:00 PM Oxycontin dose, but no Oxycontin removal was documented; the nurse later stated she had not realized the resident had Oxycontin ordered, gave oxycodone instead, and did not document an explanation for not giving the Oxycontin. On a separate date, another nurse initialed the 10:00 AM Oxycontin dose as administered on the MAR, but there was no corresponding removal on the controlled drug record, and the nurse could not recall why the documentation did not match. The DON stated she expected removal documentation from locked storage to coincide with MAR documentation of administration.
Inaccurate Documentation of Bowel Movements and Controlled Medications
Penalty
Summary
The deficiency involves the facility’s failure to maintain accurate and complete medical records for two residents, specifically regarding bowel movement documentation and controlled medication administration. One resident with Stage IV basal cell carcinoma had only three bowel movements documented over a nineteen-day stay, despite nursing staff and the DON acknowledging that the resident had more bowel movements than recorded. The facility’s system was designed to flag when a resident went three days without a bowel movement so that medications could be administered if needed, but the actual frequency of bowel movements was not accurately reflected in the medical record. For the same resident, record review showed multiple instances where hydrocodone-acetaminophen and oxycodone were removed from controlled drug storage, as documented on the Controlled Drug Record, but there was no corresponding documentation of administration on the MAR. Nurse #1 confirmed that she had administered both hydrocodone-acetaminophen and oxycodone at the times she signed out the medications but failed to document these administrations on the MAR. Another nurse (Nurse #6) also reported administering a dose of hydrocodone-acetaminophen that she removed from storage but forgot to sign for on the MAR. The DON stated that the resident was at risk for constipation due to pain medications and acknowledged that the record was incomplete and did not accurately reflect the resident’s status. A second resident with vertebrae osteomyelitis and low back pain had an order for scheduled Oxycontin and PRN oxycodone for breakthrough pain. Review of this resident’s MAR and Oxycontin Controlled Drug Record showed that a nurse (Nurse #13) initialed that a scheduled Oxycontin dose was given, even though she did not administer it because the resident appeared sedated. Nurse #13 explained that she had signed the MAR before deciding to hold the dose and was unfamiliar with how to correct the electronic MAR to show that the medication was not actually administered. She confirmed that the medical record was therefore not accurate. The interim Administrator stated an expectation that medical records be complete regarding documentation of bowel movements and controlled medications.
Failure to Arrange Transportation for Critical Follow-Up Appointments
Penalty
Summary
The facility failed to ensure that transportation was arranged for a resident’s scheduled follow-up oncology and nephrology appointments after discharge from the hospital and admission to the facility. The resident had Stage IV basal cell carcinoma with metastatic disease to the lung and bone, as well as Stage IV kidney disease. The hospital discharge summary included multiple diagnostic and physician appointments for a specific date, including a preclinical PET scan and visits with an oncologist and nephrologist, with times, departments, and locations clearly listed. A physician progress note documented that the resident’s family member informed the physician that an oncology follow-up was scheduled in about 10 days and asked whether transportation could be arranged. On the day of the scheduled appointments, the family member went to the oncology appointment expecting to meet the resident there, believing the facility had arranged transportation, but the resident did not arrive and all appointments were missed. Interviews and record review showed that the facility’s internal process for reviewing hospital discharge summaries and arranging transportation was not followed for this resident. The Transportation Nurse Aide stated that nursing staff are supposed to read the discharge summary for new admissions and then give it to her so she can identify and arrange transportation for any listed appointments. She reported that she never received this resident’s discharge summary, was not informed of the scheduled appointments, and therefore did not arrange transport, although she could have taken the resident if she had known. The Social Worker stated she was unaware of the missed appointments and that the Transportation Nurse Aide routinely checked discharge summaries and arranged transport, with the Social Worker assisting if the aide was absent. The DON confirmed that the Transportation Nurse Aide should have been given the discharge summary to arrange transportation but this did not occur, and the admitting nurse who might have provided further information was unavailable for interview due to a personal emergency.
Failure to Provide Timely Pain Medication to Resident With Metastatic Cancer
Penalty
Summary
The deficiency involves the facility’s failure to provide timely, ordered pain management to a cognitively intact resident with stage IV basal cell carcinoma metastatic to lung and bone, an open malignant wound to the posterior left shoulder, neuropathy, and a history of cervical and thoracic spine surgery. The resident’s admission MDS documented frequent moderate pain interfering with daily activities, with reported pain up to 7/10, and the care plan directed staff to encourage the resident to request PRN pain medication and to offer it as ordered. Physician orders included hydrocodone 5-325 mg every four hours PRN, oxycodone 10 mg every six hours PRN, and gabapentin 800 mg three times daily. The resident’s family member reported that the resident had told him it often took a couple of hours after calling before staff administered pain medication, describing this as a general problem rather than a single incident. On the evening in question, assignment sheets showed that one nurse was assigned to the resident beginning at 7:00 PM. The MAR for that date showed the evening gabapentin dose was documented with another nurse’s initials, with no time of administration, and the first oxycodone dose on that shift was not given until 1:48 AM the following day, with no hydrocodone documented for that shift. A nurse aide who cared for the resident that evening reported that during initial rounds between 7:00 PM and 7:30 PM, the resident requested pain medication, and she relayed this to the assigned nurse, who said she would get to it. Around 8:30 PM, the resident again reported he still had not received pain medication, and the aide stated she could not locate the assigned nurse despite repeatedly looking for her and observing that the nurse’s medication cart remained in the same place. The aide reported the resident repeatedly called out that he was in pain and that he did not go to sleep because he was hurting. Another nurse, assigned to a different unit, reported being alerted by staff that the assigned nurse was asleep in her car while residents on that unit, including this resident, needed medications. She stated she could not access the resident’s medications because the assigned nurse had the keys to the medication cart. She contacted the on-call nurse and the DON for assistance and was instructed multiple times to try to awaken the assigned nurse in her car. She and other staff attempted to wake the assigned nurse, who briefly cracked the car door but did not return to the building and went back to sleep. The DON reported receiving calls about the situation later that night, directing staff to awaken the assigned nurse and instructing her to return inside, and then ultimately coming to the facility after midnight, having the assigned nurse reconcile controlled substances, and sending her home. The assisting nurse stated that by the time the DON arrived, the resident still had not received pain medication, and that she was only able to administer oxycodone around 2:00 AM, at which time the resident had tears in his eyes and rated his pain as 20/10. The assigned nurse later stated she had not been feeling well, had gone to her car for a break, and was not aware the resident was in pain or that he had not received pain medication.
Failure to Complete STAT X‑Ray After Fall With New Left Leg Pain
Penalty
Summary
The deficiency involves the facility’s failure to obtain a STAT mobile x‑ray as ordered after a resident fall and subsequent complaint of left leg pain. The resident had multiple significant diagnoses, including end stage renal disease, pulmonary hypertension, COPD, chronic respiratory failure, CHF, atrial fibrillation, sick sinus syndrome with pacemaker, hypertension, Type 2 diabetes, osteoarthritis, gait difficulty, muscle weakness, and disability-related activity limitations. An admission MDS showed severely impaired cognition but ability to understand and be understood, no prior falls since admission, and receipt of dialysis and multiple therapies. The care plan identified the resident as at risk for falls related to debility and difficulty walking, with a goal to remain free from falls with major injury. On the morning of 02/16, the resident was found on the floor by nurse aides after reportedly sliding off the bed while trying to sit on the edge. The wound care nurse (Nurse #2) assessed the resident, documented no injuries, and the resident denied pain; range of motion of all extremities was reportedly normal, and the resident was talking about going shopping. Nurse aides who assisted confirmed that the resident did not complain of pain and was able to move all extremities. Nurse #2 stated she notified the resident’s representative (RR) about this first fall, although the event report erroneously documented notification of the resident instead of the RR. Later that day, the NP assessed the resident for gout pain in the left great toe and also checked her leg because of the earlier fall, finding normal range of motion and no signs of pain or suspicion of hip fracture at that time. Late that night on 02/16, a second fall was documented by Nurse #1 as a late entry. Nurse #1 recorded that the resident was found on the floor at the bedside, denied hitting her head, and had no bruising or bleeding, but did complain of left leg pain on assessment with range of motion, though no deformity was noted. Nurse #1 notified the on‑call physician and obtained a STAT order for x‑rays of the left femur and hip related to the fall, and documented notifying the RR. The DON later stated that STAT mobile x‑rays were normally completed within four hours. However, the ordered STAT x‑ray was not completed that night. The DON reported that the mobile x‑ray company indicated the responding technician was new, did not have the door code, and was unable to reach staff by doorbell or phone, so the exam was not performed. On the morning following the second fall, the RR arrived and reported the resident was moaning in pain and requested Tylenol before dialysis. Nurse #3 stated she initially did not perform a full assessment because she relied on Nurse #1’s prior assessment and the existing STAT x‑ray order, but later recalled that, after the RR voiced concern about pain, she assessed the resident by listening to lungs, palpating the abdomen and both hip areas, and bending both legs at the knees. She reported the resident denied pain, did not verbalize pain during the assessment, and only grimaced or closed her eyes with movement; she stated she administered Tylenol but failed to document it on the MAR, and she considered the resident appropriate to attend dialysis. The DON stated she saw the resident sitting in a wheelchair laughing while waiting for transport and did not assess pain at that time, and that she contacted the NP, who reportedly said that if the resident was not in distress it was acceptable to proceed with dialysis and obtain the x‑ray later. The mobile x‑ray technician arrived later that day to perform the STAT x‑ray but the resident had already left for dialysis, and the technician indicated the exam would be rescheduled. Nurse #3 documented that the RR reported the resident was having left leg pain when being repositioned before dialysis, that the resident grimaced with movement, and that Tylenol was given. The DON stated she had delegated a call to the dialysis unit to check on the resident’s status; the dialysis nurse reportedly told facility staff that the resident was sleeping and had no complaints of pain, although the dialysis provider’s documentation showed the resident continued to complain of left lower extremity pain during dialysis and requested to end treatment early. The NP later reviewed the case and noted that, given the resident’s diagnoses and the presence of a hip fracture, she had been at risk for shortness of breath or a cardiovascular event during transfer to dialysis, but that she had not experienced these outcomes. The RR reported she believed the resident should have been sent to the hospital after the second fall and that she learned at the hospital that the resident required surgery for a hip fracture. The facility’s failure to ensure that the ordered STAT x‑ray was obtained promptly after the second fall, and to complete timely diagnostic evaluation of the resident’s reported left leg pain, constituted the deficiency.
Significant Medication Errors Due to Missed Insulin Doses and Failure to Discontinue Steroid
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, as evidenced by missed doses of scheduled rapid-acting insulin for two residents and a failure to discontinue a steroid medication as recommended for another resident. For two residents with diabetes, scheduled doses of insulin aspart were not administered in the morning due to a staffing issue. The Medication Administration Records (MAR) indicated that the morning doses were missed, and there was no documentation of blood sugar readings prior to the scheduled administration times. The nurse on duty reported that he was only notified of the need to pass medications after arriving late, and by that time, it was already time for the next scheduled insulin doses. The physician was informed and directed staff to hold the missed doses and proceed with the next scheduled administration. Both residents did not experience adverse events from the missed doses, but the medications were not given as ordered. Another resident with a diagnosis of pulmonary sarcoidosis continued to receive prednisone, a corticosteroid, despite a pulmonologist's consultation recommending discontinuation of the medication. The consultation report was signed by the unit manager, but the order to discontinue prednisone was not implemented until several months later. The MAR showed that the resident continued to receive prednisone every other day until the order was finally discontinued. Interviews with the previous DON and medical directors revealed that the consultation report was either not reviewed with the physician or the recommendation was not acted upon in a timely manner. The administrator was unaware that the consultation report had not been reviewed and that the medication had not been discontinued as recommended. These deficiencies were identified through record review, staff and resident interviews, and review of consultation reports. The facility's failure to administer medications as ordered and to follow up on consultation recommendations resulted in significant medication errors for three residents. The events were attributed to staffing issues, lack of communication, and failure to implement physician recommendations in a timely manner.
Insufficient Nursing Staff Leads to Missed Insulin Doses
Penalty
Summary
The facility failed to ensure sufficient nursing staff were present to meet the needs of all residents, resulting in significant medication errors for two residents with diabetes. On the morning in question, two of three assigned staff members, a Medication Aide and a Unit Manager, did not report to work as scheduled. This left only one nurse on duty for the three units, and the absence of staff was not promptly addressed, leading to a delay in medication administration. As a result, two residents who required scheduled morning doses of rapid-acting insulin did not receive their medication as ordered. One resident, who was cognitively intact, reported not receiving his insulin after breakfast due to the absence of the assigned staff member. The other resident, who had severe cognitive impairment, also missed the scheduled insulin dose. The Medication Administration Records confirmed that the insulin was not administered, and notes indicated the missed doses were due to overlapping doses from late administration, with the physician being made aware. Interviews with staff revealed that the scheduler was aware of the staffing shortage early in the shift and attempted to find replacements but was unsuccessful. The previous DON and other nursing staff arrived later in the day, but by that time, the morning medications had already been missed. Communication lapses among staff contributed to the delay in addressing the staffing issue, and the absence of key personnel directly led to the failure to administer critical medications as scheduled.
Failure to Follow Care Plan for Safe Transfer Results in Resident Fracture
Penalty
Summary
A deficiency occurred when a resident, who had a history of cerebral vascular accident, hemiplegia, hemiparesis, heart failure, and diabetes mellitus, was transferred from a wheelchair to a bed by a nurse aide without the use of a mechanical lift, as required by the resident's care plan. The resident was documented as cognitively intact but dependent on staff for transfers and had range of motion impairment on one side. The care plan specifically indicated the need for a mechanical lift for all transfers. On the day of the incident, the agency nurse aide performed a one-person assist transfer, lifting the resident manually from the wheelchair to the bed. The aide did not use the mechanical lift, despite being instructed by another nurse aide to do so and being informed that assistance was available if needed. The resident reported being picked up and thrown onto the bed, resulting in immediate pain. The aide acknowledged performing the transfer alone and stated that the resident complained of mild pain, which was reportedly relieved with repositioning. Following the transfer, the resident experienced significant pain and swelling in the left knee, which was assessed by nursing staff. The pain persisted despite administration of acetaminophen and other interventions. The resident was eventually sent to the emergency department, where imaging revealed a comminuted and displaced fracture of the distal femur. The incident was confirmed through interviews with staff and review of documentation, which showed that the transfer was not performed according to the resident's care plan and that the required mechanical lift was not used.
Failure to Update Facility Assessment for Tracheostomy Care
Penalty
Summary
The facility failed to annually review and update its facility-wide assessment, which is necessary to determine the resources required to care for residents competently during both day-to-day operations and emergencies. This oversight had the potential to affect all 80 residents in the facility. Specifically, the facility assessment inaccurately indicated that there were no residents requiring tracheostomy care, despite medical records showing that two residents had tracheostomies and required such care. The facility was unable to provide documentation demonstrating that the facility assessment had been reviewed and updated since 2023. During an interview, the Administrator acknowledged that it was her responsibility to ensure the facility assessment was current and admitted she was unaware that the assessment was outdated, having forgotten to conduct a review in 2024.
Inaccurate MDS Coding for Residents
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) assessments for several residents, leading to discrepancies in their medical records. Resident #15, who was admitted with end-stage renal disease and initially required dialysis, had improved kidney function and no longer needed dialysis upon discharge back to the facility. However, the MDS assessment incorrectly indicated that the resident was still receiving dialysis due to an assumption made by MDS Nurse #1 based on a physician order for monitoring the shunt site. Resident #57, diagnosed with vascular dementia, had an active physician order for a wander guard alarm, which was in place as per the Medication Administration Record (MAR). Despite this, the MDS quarterly assessment failed to reflect the use of the wander guard alarm. MDS Nurse #1 acknowledged missing this detail during the assessment process. Similarly, Resident #44, who had diabetes and was on insulin glargine, was not coded for the use of hypoglycemic medication in the MDS assessment, an oversight admitted by MDS Nurse #1. Resident #70, who was readmitted to the facility with end-stage renal disease and dependence on dialysis, was not correctly coded in the MDS assessment to reflect his dialysis treatment. The resident had been hospitalized for sepsis and returned without dialysis orders, but the MDS should have indicated the ongoing need for dialysis. The Director of Nursing noted that the dialysis order was not reinstated upon the resident's return from the hospital. In all cases, the Administrator confirmed that the MDS Nurse was responsible for ensuring accurate coding of resident assessments.
Medication Management and Security Deficiencies
Penalty
Summary
The facility failed to properly label and store medications on two separate medication carts, leading to deficiencies in medication management. On Unit 3, an insulin lispro injector pen was found open without a date or resident identifiers, and an albuterol inhaler was similarly unlabeled. The Unit Manager confirmed these findings, and the Director of Nursing acknowledged that all nurses were responsible for ensuring medications were labeled and dated. Additionally, on Unit 1, a netarsudil ophthalmic solution was found unrefrigerated, contrary to the manufacturer's storage recommendations. The Director of Nursing stated that nurses were responsible for checking medication storage. Furthermore, the facility failed to secure a wound treatment cart on Unit 3, which was found unattended and unlocked. The cart contained resident creams, ointments, medicated dressings, and treatment supplies. The Administrator and Nurse #2 were present at the nursing station but did not notice the unlocked cart until it was pointed out by the surveyor. The Director of Nursing confirmed that the cart should have been locked when unattended, and all nursing staff were aware of this requirement.
Failure to Maintain Sanitary Kitchen Conditions
Penalty
Summary
The facility failed to maintain kitchen equipment in a clean and sanitary condition, which could potentially lead to cross-contamination of food served to residents. During a lunch meal observation, the two-cylinder plate dispenser was found with dark dried food particles at the bottom of both cylinders, and the plate tray had dried liquid stains. This condition was observed on two consecutive days, indicating a lack of regular cleaning. The District Dietary Manager acknowledged that the plate dispenser was kept plugged in at all times, and staff had overlooked cleaning inside the cylinders. Additionally, the shelf under the steam table was observed to be covered with dark dried food particles during kitchen inspections. Despite having a weekly cleaning schedule that included the steam table, the Certified Dietary Manager admitted that the cleaning was not adequately performed. The Administrator confirmed that the dietary staff should maintain cleanliness in all kitchen areas, including the plate dispenser and steam table shelves, but these areas were neglected in the cleaning routine.
Improper Garbage Disposal in Dumpster Area
Penalty
Summary
The facility failed to ensure proper disposal of garbage and refuse, as observed in the dumpster area. On the morning of January 7, 2024, a large bag of garbage was seen hanging out of the lid of Dumpster #1, and two disposable gloves were found on the ground behind it. Later that afternoon, the lid and right-side door of Dumpster #1 were open, with additional litter, including three disposable gloves, a soda bottle, and straw papers, scattered around the area. The Dietary District Manager confirmed that the area had been cleaned earlier that day, but the waste company did not pick up the dropped items. The facility's Administrator stated that all staff were responsible for maintaining the cleanliness of the dumpster area, and the Corporate Administrator suggested assigning a staff member to inspect the area daily.
Failure to Complete MDS Significant Change Assessment for Hospice Admission
Penalty
Summary
The facility failed to complete a Minimum Data Set (MDS) Significant Change in Status Assessment for a resident who was admitted with a diagnosis of malignant neoplasm. The resident was initially identified as cognitively intact, had a tracheotomy, and was not receiving hospice services at the time of admission. However, a physician order dated 11/21/24 indicated that the resident was to be admitted to hospice due to the terminal diagnosis, with a life expectancy of six months or less. Despite this significant change in the resident's status, there was no documentation in the medical record that an MDS significant change in status assessment had been completed to reflect the initiation of hospice services. Interviews with the MDS Nurse and the Administrator confirmed that the assessment should have been completed when the resident began receiving hospice services. The MDS Nurse acknowledged the oversight, and the Administrator stated that the MDS Nurse should have reviewed the resident for a significant change in status assessment upon the election of hospice services.
Failure to Develop Person-Centered Care Plan for Resident
Penalty
Summary
The facility failed to develop a person-centered care plan for a resident with severe cognitive impairment, who had expressed specific activity preferences. The resident, admitted with diagnoses including stroke and dementia, indicated that activities such as reading, listening to music, attending religious services, and being outdoors were very important. However, the resident's care plan, last reviewed in early January 2025, did not include any provisions related to these activity preferences. Observations over several days showed the resident consistently in their room with the television on, and the responsible party was unaware of any activities provided by the facility. Interviews with facility staff revealed a lack of clarity and responsibility regarding the development and implementation of the resident's activity care plan. The Activity Director, who had been in the role for over a year, admitted to not having created care plans previously and only recently being shown how to do so. The MDS Nurse indicated that the Activity Director was responsible for the activity-focused care plan, while the Administrator expected the MDS Nurses to assist when needed. This lack of coordination and clear responsibility led to the deficiency in providing a person-centered care plan for the resident.
Failure to Obtain Physician Order for Tracheostomy Care
Penalty
Summary
The facility failed to obtain a physician order for tracheostomy care for a resident who was admitted with a tracheostomy. The resident, identified as Resident #35, was admitted with a diagnosis that included a tracheostomy and had physician orders for oxygen via tracheostomy collar and suctioning needs. However, there was no physician order documented for tracheostomy site care, and the Treatment Administration Record for December 2024 and January 2025 lacked documentation of such care. Interviews with nursing staff revealed that tracheostomy care was being provided at least once per shift, including cleaning around the tracheostomy site and suctioning as needed. Despite this, the Unit Manager confirmed that a physician order for tracheostomy care was not entered upon the resident's admission, and the Director of Nursing was unable to explain how this oversight occurred. The deficiency was identified during a survey, highlighting a lapse in ensuring proper documentation and physician orders for necessary respiratory care.
Failure to Ensure Physician's Order for Dialysis
Penalty
Summary
The facility failed to ensure that a resident receiving dialysis had a physician's order for dialysis. This deficiency was identified for a resident who was admitted with end-stage renal disease and was dependent on renal dialysis. The resident's care plan included specific instructions for managing dialysis-related care, such as coordinating with the dialysis center and monitoring the shunt site. However, after the resident was readmitted from the hospital, the dialysis order was not reinstated, and this oversight was confirmed through staff interviews. The deficiency was further highlighted when the resident was sent to dialysis without a documented physician's order. Interviews with the Unit Manager and the Director of Nursing revealed that the staff failed to reestablish the dialysis order upon the resident's return from the hospital. The Administrator also acknowledged that the staff should have ensured the presence of a physician's order for dialysis. This lapse in documentation and communication led to the deficiency being cited during the survey.
Failure to Notify Ombudsman of Resident Transfers
Penalty
Summary
The facility failed to notify the Ombudsman in writing of resident transfers to the hospital for two residents. Resident #35 was transferred to the hospital on two occasions, but the Ombudsman was not notified of these transfers. The Social Service Director, who started in the position in July 2024, was running the wrong report, which did not show any resident transfers or discharges. This error was discovered during interviews with the Ombudsman and the Social Service Director, who admitted to not knowing how to run the correct report until recently. Similarly, Resident #11 was transferred to the Emergency Department on two occasions due to changes in condition, but there was no documentation that the Ombudsman was notified of these transfers. The Director of Nursing and the interim Administrator confirmed that it was the responsibility of the Social Service Director to send these notifications, but they were unaware that the notifications were not sent. The deficiency was identified through record reviews and staff interviews, highlighting a lapse in the facility's notification process to the Ombudsman.
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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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