Siler City Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Siler City, North Carolina.
- Location
- 900 W Dolphin Street, Siler City, North Carolina 27344
- CMS Provider Number
- 345143
- Inspections on file
- 20
- Latest survey
- March 13, 2026
- Citations (last 12 mo.)
- 8 (1 serious)
Citation history
Health deficiencies cited at Siler City Center during CMS and state inspections, most recent first.
A resident with a left patella fracture was admitted with hospital instructions that a knee immobilizer be worn when bearing weight and removed when not weight-bearing, but facility staff transcribed the order as requiring the immobilizer to be in place at all times, with removal only for bathing and skin checks. Admission notes documented existing skin concerns and redness at the left knee, yet the MDS and care plan did not reflect these findings or include specific interventions for the immobilizer. Over several weeks, nurses and NAs often did not fully remove the immobilizer for skin assessments, some documented normal skin or no external device, and one nurse later admitted seeing redness and indentations from the brace without reporting or documenting them. Eventually, an NA noticed drainage on the bed sheet, opened the immobilizer, and found an open wound on the back of the resident’s lower leg at the edge of the device; the wound was documented as a new, in-house acquired pressure ulcer, while the immobilizer remained in place and continued to press on the wound until it was removed days after a verbal order from an orthopedic NP.
Surveyors found multiple food service sanitation deficiencies, including a flour scoop stored directly in a flour bin instead of being kept to avoid contact with the food, a steam table hood with visible orange-brown residue and a slick surface that had not been cleaned recently, and plastic plate bases stacked while still wet on the tray line. The Dietary Manager acknowledged the issues with the scoop placement, the lack of recent cleaning under the hood, and that she had not checked the plastic plate bases for dryness, while the Administrator reported being unaware of why these conditions occurred.
A cognitively intact resident with a physician’s order for fluticasone nasal spray for allergies was observed multiple times with the prescribed nasal spray left on the overbed table for self-use, without any documented assessment, physician order, or care plan for self-administration. The resident reported that a nurse had left the spray in the room and acknowledged it was not supposed to be there, but that it made use easier. A nurse assigned to the resident stated she was unsure of the self-administration process, believed no residents on that hall self-administered medications, and had not noticed the spray earlier when giving medications, only discovering and removing it during an interview. The DON and Administrator described a process requiring evaluation, orders, a lock box, and care plan interventions for self-administration and indicated these steps had not been completed for this resident, despite the medication being kept at bedside.
A resident with multiple comorbidities, including CHF and Alzheimer’s disease, was admitted with documented skin issues such as a dark spot on the coccyx, an open area on the spine, and knee redness. The care plan identified risk for skin breakdown and outlined general preventive skin care measures, but did not specifically address the documented open area or dark spot. The admission MDS inaccurately recorded that the resident had no pressure ulcers, scars over bony prominences, or other skin problems, and did not indicate the need for a pressure-relieving device, repositioning/turning program, or nutrition/hydration program for skin, resulting in an inaccurate MDS skin assessment.
A resident with a physician order prohibiting self-administration of medications and requiring monitored swallowing was found with a cup containing seven pills left on the bedside table after the assigned nurse had finished passing meds on the hall. The nurse reported these were the resident’s lunch meds, stated that the resident usually took them when handed to him, and admitted she trusted the resident to take them after he said he would, despite later refusal in her presence. The nurse acknowledged knowing the resident was not to have meds at the bedside and that she was required to monitor and document swallowing. The physician confirmed he expected staff to follow orders, and the DON stated that only one resident in the facility was authorized to self-administer medications, while all others, including this resident, were not.
Surveyors found that the trash compactor area, located behind the kitchen entrance, was not properly maintained, with multiple plastic bottles, disposable cups, gloves, and straws scattered in the grassy area beside the compactor. The DM stated that kitchen staff cleaned only the cement platform weekly and that the surrounding grassy areas were not being picked up, despite the compactor being used by all departments. The Administrator acknowledged he did not know why the area had not been cleaned and stated he would want the area free of debris.
A resident with dementia and a history of physical aggression toward others repeatedly struck other residents, including one cognitively impaired resident at the nurses’ station, a cognitively intact roommate during a dispute over television volume, and another severely cognitively impaired resident who approached too closely, even while the aggressive resident was on 1:1 supervision. Care plans for the involved residents documented behavioral symptoms, mood disturbances, and wandering, and called for monitoring for aggression, removal from triggering environments, and diversion. However, staff at the nurses’ station were unable to separate residents in time to prevent a slap, the assault with a reaching device in a shared room was unwitnessed, and NAs assigned to 1:1 supervision reported they were not informed of the aggressive resident’s specific triggers or the reasons for the 1:1, contributing to the failure to prevent these resident-to-resident abuse incidents.
Two cognitively impaired male residents, both lacking capacity to consent, were involved in an incident where one was observed grasping and moving the other's exposed penis in a shared room. Neither had a prior history of sexually inappropriate behavior, and their care plans did not address such risks. The event was discovered by a nurse aide who intervened immediately, but the absence of prior identification or monitoring for sexual behaviors contributed to the deficiency.
A resident with COPD, diabetes type 2, and hypertension was found with medications left unsecured on their over the bed table without a physician's order for self-administration. The resident, who was cognitively intact, did not indicate an intention to take the medications. A nurse left the medications assuming the resident would take them, but later retrieved them when the resident refused. The DON confirmed that medications should not be left unsecured without an order.
The facility failed to ensure privacy in mail delivery for three cognitively intact residents, who reported receiving opened mail related to their financial status. The Business Office Manager admitted to opening all mail without verifying the addressee, especially if it was financial. The Administrator was unaware of this practice, which breached residents' privacy.
A resident with a feeding tube was not receiving water flushes at the physician-ordered frequency. The order specified 110 ml every 3 hours, but observations showed it was set for every 4 hours. The discrepancy was acknowledged by a nurse, and the DON expected adherence to the prescribed rate.
A resident with low blood pressure received Midodrine despite having systolic blood pressure readings above the prescribed threshold. The medication was administered on multiple occasions contrary to the physician's order, which specified it should only be given if the SBP was less than 120. Nursing staff acknowledged the oversight, and the DON and Medical Director expected adherence to the order.
A resident with moderate cognitive impairment experienced a lack of dignity due to staff failing to empty urinals in a timely manner, particularly before meals. Despite the resident's requests and the DON's expectations, urinals with urine were observed on the nightstand during meal times, indicating a deficiency in maintaining the resident's dignity.
The facility failed to provide written notification to residents or their responsible parties regarding hospital transfers, affecting four residents. Despite sending necessary medical documents with residents during transfers, the facility did not include written notices. Interviews with staff revealed a lack of awareness about this requirement, indicating a systemic issue in the notification process.
Failure to Follow Knee Immobilizer Orders and Monitor Skin, Leading to Device-Related Pressure Ulcer
Penalty
Summary
The deficiency involves the facility’s failure to follow physician and hospital discharge orders for a knee immobilizer and to provide adequate skin assessment and monitoring, resulting in a facility-acquired pressure ulcer under the device. The resident was admitted after a left patella fracture with hospital discharge instructions specifying that the knee immobilizer should be worn when bearing weight and could be removed when not bearing weight for comfort. However, when the order was transcribed into the facility’s EMR by a house supervisor, it was entered as “left knee immobilizer in place at all times. May remove for bathing and skin checks every day and night shift,” which did not match the hospital discharge instructions. Neither of the two house supervisors who handled admissions could explain where the “at all times” language originated, and no documentation was produced to support that wording. The resident was admitted with multiple diagnoses including left patella fracture, A-fib, CHF, hypothyroidism, Alzheimer’s disease, and later-documented moderate protein-calorie malnutrition. On admission, nursing documentation noted a dark spot on the coccyx, an open area on the spine, and redness to the left knee, but these findings were not reflected on the admission MDS, which indicated no pressure ulcers, no other skin problems, and no malnutrition or risk for malnutrition. The care plan identified risk for skin breakdown and nutritional risk but did not include specific interventions related to the knee immobilizer or to the coccyx and spinal skin issues noted on admission. Subsequent Braden and advanced skin checks at various dates documented normal skin findings and, on at least two occasions, incorrectly indicated that the resident did not have an external device, despite the presence of the immobilizer. Throughout October and early November, the TAR carried the order for the immobilizer to be in place at all times, with removal allowed for bathing and skin checks, and nurses consistently initialed that the order was carried out. Multiple nurses and NAs reported that they either did not fully remove the immobilizer or could not recall doing so, and some stated they believed the order did not require full removal except for baths. One nurse later acknowledged seeing redness and indentations from the brace on the lower leg or back of the thigh on at least two days but did not document or report these findings, considering them not significant. Another staff member documented that the splint was removed and inspected and that no concerning changes were seen, while other staff described only partially opening the brace or being able to see the skin “fine” without fully removing it. On a follow-up visit, the orthopedic NP recommended that the resident be weight bearing as tolerated with the immobilizer and to continue the immobilizer when sitting and lying, with PT allowed to remove it for range of motion up to 60 degrees of flexion. Later, an NA providing a bed bath observed yellow drainage on the bed sheet and, upon opening the immobilizer and lifting the leg, found an open, dark-colored wound on the back of the left lower leg at the point where the immobilizer ended, with indentations all over the leg from the brace. The nurse who assessed the wound documented it as a new, in-house acquired pressure ulcer and initially mis-located it on the front lateral lower leg due to confusion with directions. The wound was described by staff as open, with red and yellow tissue and “yellowy-red” drainage, and another nurse noted that the immobilizer remained in place and was pushing into the wound. The facility contacted the orthopedic NP days later to ask about removing the immobilizer; the NP gave a verbal order to remove it and requested to see the resident the same day, but the visit was delayed due to transportation issues, and interviews indicated the immobilizer was not actually removed until several days after the verbal order, during which time it potentially continued to exert pressure on the ulcer.
Improper Food Storage and Sanitation Practices in Kitchen
Penalty
Summary
Surveyors identified a deficiency in food storage and sanitation practices in the facility’s kitchen. During an initial kitchen tour with the Dietary Manager, a large bin of flour was observed with the scoop stored directly inside the flour, rather than in a manner that prevented contact with the food product. The Dietary Manager explained that the hook intended for hanging the scoop was inside the container and that when the lid was slid closed, it often knocked the scoop back into the flour. No residents or their specific medical conditions were mentioned in relation to this observation. Further observations showed additional sanitation issues. The underside of the steam table hood was found to have orange and brown residue and felt slick to the touch, and the Dietary Manager acknowledged that while the steam table was cleaned between meals, the underside of the hood had likely not been cleaned for some time. On a follow-up kitchen tour, surveyors observed that 20 of 30 plastic plate bases on the tray line were stacked while still wet and ready for use. The Dietary Manager stated she had checked other dishware for dryness but had not checked the plastic plate bases. The Administrator later stated he did not know why the hood was not clean or why the scoop was left in the flour and indicated he would want the kitchen kept clean and dishware clean and dry before use.
Failure to Assess and Authorize Resident Self-Administration of Nasal Spray Kept at Bedside
Penalty
Summary
The facility failed to assess and authorize a cognitively intact resident’s ability to self-administer a prescribed steroid nasal spray that was kept at bedside. The resident had a physician’s order for fluticasone propionate nasal suspension, 50 micrograms, two sprays in both nostrils twice daily for allergies. The quarterly MDS documented that the resident was cognitively intact, and the DON and Medical Director both acknowledged the resident had the potential or ability to self-administer medication. However, the resident’s care plan contained no goals or interventions related to self-administration of medications, and the medical record did not contain any assessment for self-administration or an order permitting the resident to keep the nasal spray at bedside. Surveyors observed the resident’s prescribed nasal spray on the overbed table on multiple occasions over two consecutive days, and the resident stated that a nurse had left it in the room and that she knew she should not have it there, but it made it easier to use when needed. A nurse assigned to the resident stated she was unsure of the process for residents who self-administer medications, believed no residents on that hall self-administered, and said she would remove any medication found in a resident’s room, yet she had not noticed the nasal spray earlier that day when administering medications. During an interview and concurrent room observation, this nurse then discovered the nasal spray on the overbed table behind a tissue box and removed it. The DON and Administrator both described a facility process requiring an assessment, an order, a lock box, and care plan interventions for self-administration, and both stated they were not aware of residents on that hall self-administering medications, confirming that these required steps had not been completed for this resident despite the medication being left at bedside.
Inaccurate MDS Skin Assessment for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to complete an accurate MDS assessment regarding skin conditions for one resident. The resident was admitted with diagnoses including a left patella fracture, A-fib, CHF, hypothyroidism, and Alzheimer’s disease. On admission, a nurse documented a dark spot on the coccyx, an open area on the spine, and redness to the left knee. The resident’s care plan, initiated the day after admission, identified her as being at risk for skin breakdown and included general preventive skin care interventions such as patting the skin dry, observing for signs of breakdown, using barrier creams, and checking the skin weekly by a licensed nurse. Despite these documented skin findings and risk factors, the admission MDS indicated that the resident was severely cognitively impaired and required extensive assistance with ADLs but did not accurately reflect her existing skin issues. The MDS stated that the resident did not have a pressure ulcer/injury, a scar over a bony prominence, or a non-removable dressing or device, and under other ulcers, wounds, and skin problems, it indicated none were present. The MDS also did not indicate the need for a pressure-relieving device in the chair, participation in a reposition/turning program, or inclusion in a nutrition and hydration program for skin, resulting in an inaccurate assessment of the resident’s skin condition and related care needs.
Unsecured Bedside Medications Left With Resident Despite No Self-Administration Order
Penalty
Summary
The deficiency involves the facility’s failure to secure medications and prevent unauthorized self-administration for a resident who had explicit physician orders prohibiting self-administration. The resident was admitted on a specified date and had a physician’s order dated 6/25/2025 stating that he may not administer his own medications, as well as an order for staff to monitor his swallowing during medication passes and document any coughing, pain, or difficulty swallowing. During an observation on 2/24/2026 at 2:50 PM, surveyors found a medication cup containing seven pills on the resident’s bedside table while the assigned nurse was no longer passing medications on the hallway. The resident stated he would take the medications in the cup when they let him out of the facility. At 2:55 PM the same day, the assigned nurse confirmed that the cup contained the resident’s lunch medications, which she had given him at approximately 1:30 PM, and acknowledged that he usually took them when handed to him. When the nurse asked the resident to take the medications, he refused, repeating that he would take them when he got up out of there, and did not take them at that time. The nurse then removed the medication cup and later stated she had trusted the resident would take the medications and recognized this as a lapse in judgment, acknowledging she knew he was not to have medications left at the bedside and that she was required to monitor and document his swallowing. The physician later stated he did not recall the no self-administration order but agreed that if such an order existed, the resident probably should not self-administer, and he expected staff to follow physician orders. The DON confirmed that only one resident in the facility had an order to self-administer medications and that all others, including this resident, had orders that they may not self-administer medications.
Failure to Maintain Clean Trash Compactor Area
Penalty
Summary
Surveyors observed that the facility failed to keep the area around the trash compactor free of accumulated trash and debris. During an observation of the dumpster area with the Dietary Manager, the trash compactor was seen in a fenced area behind the kitchen entrance, with a cement platform in front and grassy areas to the left and back. In the grassy area on the left side of the compactor, surveyors noted four plastic bottles, six disposable cups, four disposable gloves, and seven straws that had not been removed. The Dietary Manager reported that a member of the kitchen staff cleaned only the cement platform on a weekly basis and confirmed that the trash and debris on the left side and back of the trash compactor were not being picked up. The Dietary Manager stated she did not know why those areas were not attended to and noted that all departments in the facility used the same trash compactor. In a separate interview, the Administrator stated he did not know why the trash compactor area had not been cleaned and indicated he would want the area free of debris.
Failure to Prevent Repeated Resident-to-Resident Physical Abuse Despite Known Behavioral Risks
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from physical abuse, specifically resident-to-resident altercations involving one resident with dementia and behavioral symptoms. This resident had diagnoses including dementia, psychotic and mood disturbances, and anxiety, and was assessed as severely cognitively impaired with no physical limitations. His care plan, revised multiple times, documented a history and risk of physical behaviors toward others, including prior resident-to-resident incidents. Despite this, his MDS assessments did not reflect behaviors directed toward others during the lookback periods, and the care plan interventions relied on staff recognizing triggers, observing for non-verbal signs of aggression, and removing or diverting the resident as needed. On one occasion, an altercation occurred between this resident and another cognitively impaired resident with dementia and depressive disorder. The second resident’s care plan documented physical behaviors such as grabbing, pushing, and aggression, as well as verbal behaviors including threatening, cursing, agitation, and delusions. Staff accounts and the facility’s investigation showed that the first resident reported finding the second resident in his room going through his belongings, after which an unwitnessed altercation occurred in the room. Shortly afterward, in front of the nursing station, staff observed the first resident, visibly upset and speaking in broken English, approach the second resident and strike him in the face with an open hand. Staff present at the nursing station were unable to separate the residents quickly enough to prevent the slap. In a separate incident, the same resident with dementia shared a room with another resident who was cognitively intact but had psychiatric diagnoses including schizoaffective disorder, major depressive disorder, bipolar disorder, PTSD, and a history of hallucinations. This roommate’s care plan noted fluctuating mood, agitation, and anxiety, with interventions focused on redirection and observation for worsening psychiatric symptoms. Staff reported that the two roommates had argued over television volume earlier in the day, with a nursing assistant notifying a nurse about the dispute. Later, a nurse responding to the resident with dementia observed the shared room in disarray and found the cognitively intact roommate with blood on his forehead. The injured resident stated he had been struck on the head with a reaching device by his roommate, and continued to complain about the television volume. The actual assault was not witnessed by staff. Another incident involved the same aggressive resident and a severely cognitively impaired resident with vascular dementia, insomnia, and anxiety, who was known to wander, enter other residents’ rooms, and show poor awareness of personal space. This resident’s care plan included interventions such as gently guiding him from environments and diverting him with alternative activities. On the date of the incident, the aggressive resident was under 1:1 supervision near the nursing station. Witnesses, including a nurse and the nursing assistant assigned to 1:1, reported that the wandering resident approached and leaned in close to the supervised resident while speaking. Within seconds, the supervised resident stood or reached up and struck the approaching resident across the face with an open hand. The nursing assistant providing 1:1 supervision stated she was within arm’s reach but did not anticipate an altercation and was unable to intervene in time. Interviews with nursing assistants assigned to provide 1:1 supervision revealed they were not informed of the specific reasons for the supervision or of the resident’s known triggers for aggression, such as others touching his belongings or entering his personal space. One assistant reported only being told to notify a nurse if the resident became upset, and another stated she had not received instructions about triggers or what to avoid. The DON acknowledged being unaware whether NAs assigned to 1:1 supervision were educated about the resident’s triggers, while the ADON stated that staff were supposed to be told triggers but could not recall any formal in-service specific to this resident’s aggression. These gaps in communication and implementation of individualized interventions contributed to repeated resident-to-resident physical abuse incidents involving the same resident, including one that occurred while he was on 1:1 supervision.
Failure to Protect Cognitively Impaired Resident from Sexual Abuse by Another Resident
Penalty
Summary
A deficiency occurred when a cognitively impaired male resident was not protected from sexual abuse by another cognitively impaired male resident. The incident took place in a shared room within the memory care unit, where a nurse aide overheard unusual laughter from one resident and, upon entering the room, observed one resident lying in bed with his penis exposed while the other resident was standing beside the bed, grasping and moving the exposed penis in an up and down motion. Both residents were severely cognitively impaired and lacked the capacity to consent to sexual activity. The nurse aide immediately intervened by instructing the resident to stop and separated the two individuals. Prior to the incident, neither resident had a documented history of sexually inappropriate behaviors. Both residents had care plans that addressed other behavioral symptoms such as wandering, disrobing in public, and physical or verbal behaviors, but there were no interventions or monitoring in place for sexually inappropriate conduct. The residents were both independent with eating, bed mobility, and transfers, but required staff assistance for other activities of daily living. One resident was being treated for a urinary tract infection and had been observed pulling at his groin area earlier that morning, but this behavior had not previously been associated with sexual activity. The facility's staff, including the nurse aide, nurse, unit manager, DON, and administrator, confirmed that neither resident had previously exhibited inappropriate sexual behaviors. The incident was witnessed directly by the nurse aide, and subsequent interviews with staff and responsible parties indicated that the event was unexpected and not anticipated based on the residents' prior behavior or care plans. The lack of identification and intervention for potential sexually inappropriate behaviors in the care planning process contributed to the failure to protect the resident from abuse.
Removal Plan
- Both residents were separated and placed on one-to-one supervision by facility staff.
- Staff that witnessed the event were interviewed by the Nurse Supervisor and statements were obtained.
- The Nurse Supervisor interviewed both residents regarding the occurrence.
- Resident #2 was moved to a different room.
- Responsible Parties for both residents were notified by the licensed nurse.
- The Medical Director and Nurse Practitioner were notified of the occurrence.
- The local Police Department was notified by the Nurse Supervisor.
- Licensed Nurse conducted skin assessments on both residents.
- An initial report was sent to the North Carolina Department of Health and Human Services.
- Adult Protective Services was notified of the allegation of resident abuse.
- Psychiatric services was notified for Resident #1; a telehealth and follow-up in-person visit were conducted.
- Medication changes were recommended and implemented for Resident #1 (increased Depakote, Hydroxyzine as needed).
- Resident #2’s Zoloft was increased to decrease libido.
- A chart review was completed for both residents by the Director of Nursing.
- Skin assessments were completed on all non-alert/oriented residents by licensed nursing staff.
- Social Worker Director and Assistant Social Worker interviewed all alert and oriented residents regarding resident abuse.
- Residents with roommates were interviewed to ensure roommate compatibility.
- Medical record audit of all residents was completed to identify residents with behaviors and review for sexual behaviors.
- Residents identified as having behaviors are reviewed in clinical morning meetings to ensure appropriate interventions are in place.
- Interventions for residents with behaviors include medication regimen review, one-to-one supervision, psychiatric consultation/visit, physician notification and assessment, and roommate compatibility.
- Education was provided to all facility staff (including agency staff) on the abuse policy with emphasis on sexual behaviors, management of symptoms, and ensuring resident safety by reporting, identifying, preventing, and managing behavioral symptoms.
- Any staff not receiving abuse education will not be allowed to work before receiving education.
- All newly hired staff, including new agency staff, will be educated on the facility's abuse prohibition policy in new hire orientation.
- The Director of Nursing and Nurse Practice Educator are tracking abuse education to ensure no staff works prior to receiving education.
Failure to Obtain Physician's Order for Self-Administration of Medications
Penalty
Summary
The facility failed to assess and obtain a physician's order for the self-administration of medications for a resident diagnosed with chronic obstructive pulmonary disease, diabetes type 2, and hypertension. The resident was cognitively intact and displayed no behaviors or rejection of care according to a quarterly Minimum Data Set assessment. However, a review of the resident's medical record did not reveal an order to self-administer medications. During an observation, medications were found in a medication cup on the resident's over the bed table, which the resident stated had been left there since breakfast. The resident did not indicate an intention to take the medications. An interview with a nurse revealed that she had left the morning medications on the over the bed table for the resident to take, assuming the resident would do so. When the nurse returned, the resident stated he did not want to take them at that time, leading the nurse to retrieve the medications and mark them as refused on the Medication Administration Record. The Director of Nursing confirmed that medications should not be left unsecured at the bedside unless there is an order for self-administration, which the resident did not have.
Breach of Resident Mail Privacy
Penalty
Summary
The facility failed to ensure that residents had reasonable access to and privacy in their use of communication methods, specifically regarding the delivery of mail. Three residents, all cognitively intact, reported receiving mail that had been opened prior to their receipt. These residents were unable to provide specific dates but indicated that the opened mail was related to their financial status. The Activity Director confirmed that mail was sometimes delivered taped closed, indicating it had been opened previously. The Business Office Manager admitted to opening all mail without checking the addressee, especially if the mail was related to financial matters. She stated that she opened mail for residents with impaired cognition but acknowledged that she should not open mail for cognitively intact residents. The Administrator was unaware of this practice and confirmed that mail should only be opened if addressed to the facility or if the resident was cognitively impaired. The improper handling of mail led to a breach of privacy for the residents involved.
Failure to Administer Water Flushes at Prescribed Rate
Penalty
Summary
The facility failed to administer water flushes via a feeding tube at the physician-ordered flow rate for a resident with a feeding tube. Resident #22, who was admitted with diagnoses including dysphagia and the presence of a feeding tube, was observed to have her feeding tube connected to a continuous bottle of formula with a standby bag of water. The physician's order specified that the feeding tube should be flushed with 110 milliliters of water every 3 hours during continuous feedings. However, observations revealed that the water flush was set to run every 4 hours instead of the prescribed 3-hour interval. During an observation with Nurse #1, it was confirmed that the water flush settings were incorrect, with the frequency set at every 4 hours instead of the ordered 3 hours. Nurse #1 acknowledged the discrepancy after reviewing the physician orders but was unable to explain why the settings differed from the physician's order. The Director of Nursing later stated that she expected water flushes to be administered at the prescribed rate, indicating a failure in adhering to the physician's orders for Resident #22's care.
Failure to Adhere to Blood Pressure Medication Parameters
Penalty
Summary
The facility failed to adhere to a physician's order regarding the administration of Midodrine, a blood pressure medication, for a resident diagnosed with low blood pressure. The order specified that the medication should only be administered if the resident's systolic blood pressure (SBP) was less than 120. However, a review of the Medication Administration Records (MARs) for October and November 2024 revealed that the resident received the medication on multiple occasions when the SBP was above 120. Specific instances included SBP readings of 122, 124, and even as high as 134, yet the medication was still administered. Interviews with nursing staff indicated that the failure to hold the medication as per the physician's order was an oversight. Nurse #5, who was responsible for administering the medication on several dates, acknowledged the error upon reviewing the MARs. Similarly, Nurse #3 also recognized the oversight during their interview. Attempts to contact other nurses involved were unsuccessful. The Director of Nursing and the Medical Director both expressed that they expected the medication to be administered according to the physician's orders, although the Medical Director noted that the deviation did not result in serious harm to the resident.
Failure to Maintain Resident Dignity by Not Emptying Urinals Timely
Penalty
Summary
The facility failed to maintain the dignity of a resident by not ensuring urinals were emptied in a timely manner, particularly before meals. Resident #41, who was moderately cognitively impaired and required assistance with toileting, was observed with urinals containing urine on his nightstand on multiple occasions. Despite expressing his desire for the urinals to be emptied more frequently, especially before meals, the staff did not consistently fulfill this request. Observations revealed that the urinals remained unemptied for extended periods, even when meals were served, which the resident found unsanitary. Interviews with nursing assistants and the Director of Nursing (DON) highlighted a lack of adherence to the expected practice of emptying urinals before meals and as needed. Nursing assistants either failed to notice the urinals or did not respond to inquiries about their last emptying. The DON acknowledged the expectation for staff to ensure urinals were emptied regularly and before meals, but this was not consistently practiced, leading to the deficiency in maintaining the resident's dignity.
Failure to Provide Written Notification for Hospital Transfers
Penalty
Summary
The facility failed to provide written notification to residents or their responsible parties (RPs) regarding hospital transfers, as required by regulations. This deficiency was identified for four residents who were transferred to the hospital on multiple occasions without receiving the necessary written notices. The facility's practice involved sending a copy of the face sheet, physician orders, medication list, DNR information, and bed hold policy with the resident during transfers, but did not include a written notice of the transfer to the resident or RP. Resident #22, who had severely impaired cognition, was transferred to the hospital twice without written notification being provided to her RP. Similarly, Resident #58, who was cognitively intact, was transferred twice without receiving the required written notices. Resident #111, with moderately impaired cognition, experienced three hospital transfers without written notification to the RP. Lastly, Resident #132, who was cognitively intact, called 911 himself for a hospital transfer, and although his POA and hospice were notified, no written notice was provided. Interviews with staff, including Nurse #2 and the DON, revealed a lack of awareness regarding the requirement for written notifications. The DON confirmed that phone notifications were made to RPs, but written notices were not sent. The Administrator was also unaware of this oversight and expected the regulation to be followed, indicating a systemic issue in the facility's transfer notification process.
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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