The Carrolton Of Lumberton
Inspection history, citations, penalties and survey trends for this long-term care facility in Lumberton, North Carolina.
- Location
- 1170 Linkhaw Road, Lumberton, North Carolina 28358
- CMS Provider Number
- 345315
- Inspections on file
- 15
- Latest survey
- February 19, 2026
- Citations (last 12 mo.)
- 9
Citation history
Health deficiencies cited at The Carrolton Of Lumberton during CMS and state inspections, most recent first.
The facility failed to maintain proper accountability and documentation for multiple residents’ controlled medications, including lorazepam, hydrocodone-acetaminophen, oxycodone, oxycodone-acetaminophen, and tramadol. Pharmacy records showed that controlled drugs were delivered, but declining count sheets were missing, narcotic book entries were absent, and delivery receipts were often signed by only one nurse or not signed at all. For one resident, lorazepam tablets were delivered for a time-limited PRN order with no evidence of administration, no inventory log, and no return to the pharmacy after discontinuation. Interviews with the DON, a unit manager, the consultant pharmacist, the pharmacy nurse consultant, and the pharmacy director revealed that no one was consistently auditing controlled medications, second-nurse verification at receipt was not reliably performed, and discontinued controlled drugs were not systematically removed from carts and returned, leading to unaccounted-for controlled substances.
A resident with heart failure, HTN, and kidney disease had an order for Metolazone with instructions to hold the dose if SBP was below 110 or DBP below 60, yet an RN repeatedly administered the medication on multiple occasions when BP readings were outside these parameters over several months. The consultant pharmacist identified and reported these discrepancies in two consecutive monthly drug regimen reviews, but the facility’s follow-through was limited to a vague note that nursing staff were educated, without clear documentation that the responsible nurse was included. In subsequent months, the pharmacist’s reviews did not address the ongoing out-of-parameter administrations, and facility nursing leadership did not review the resident’s Metolazone use to ensure compliance with the ordered BP parameters, allowing the pattern of incorrect administration to continue.
A resident with heart failure, hypertension, and kidney disease received Metolazone with ordered blood pressure hold parameters that required the dose to be withheld if systolic BP was below 110 or diastolic BP was below 60. Over several months, an RN repeatedly administered the medication on multiple occasions when the resident’s BP readings were outside these parameters, totaling 57 doses given contrary to the order. The nurse later stated she misunderstood the parameters, believing both systolic and diastolic values had to be below 110/60 to hold the dose. The NP confirmed the correct interpretation of the order, and the consultant pharmacist noted that unnecessary Metolazone could cause hypotension and increase fall risk, although no change in the resident’s condition was documented.
Multiple residents with orders for tramadol, oxycodone, and hydrocodone-acetaminophen had controlled medications documented by the pharmacy as delivered, but the facility lacked required declining count sheets and complete nurse signatures on delivery receipts. Available nurses, rather than designated staff, distributed controlled medications from delivery totes to medication carts, and the DON did not verify that medications recorded as delivered were actually placed on carts or entered into narcotic logs. Internal audits initiated after one resident’s missing tramadol uncovered additional residents with missing controlled medications and a total of hundreds of unaccounted-for tablets, while staff interviews and drug testing linked a medication aide’s suspicious behavior and positive drug screen to the period of diversion. Ordering and refill practices by a NP and the pharmacy contributed to excessive quantities of controlled medications accumulating on carts without adequate tracking.
A resident with a history of traumatic brain injury and a left chest port-a-cath placed for long-term vascular access returned from the hospital with documentation that the device was available for use and had been flushed with saline and heparin, but the facility never obtained provider orders for its care or maintenance. Over an extended period, there were no physician orders or care plan addressing the port-a-cath, and staff, including LPNs and the Unit Manager, reported they did not realize orders were needed or believed only RNs could manage the device. The DON acknowledged the port-a-cath had never been accessed or maintained at the facility, and the NP confirmed she knew the device required routine flushing but had not written orders or ensured ongoing management, resulting in the port-a-cath remaining in place without scheduled access or flushing.
The facility failed to honor resident choice regarding storage and reheating of outside food. Several cognitively intact or moderately impaired residents who were independent with eating reported disliking facility food and preferring meals brought from home or restaurants, but stated they were told they could not store cooked foods in the refrigerator or have them reheated, and that purchased food was discarded. A posted sign on the nourishment room refrigerator and interviews with the Dietary Manager and Administrator confirmed a facility policy prohibiting storage and reheating of cooked foods and disallowing personal refrigerators, while the RD indicated cooked foods can usually be safely stored for several days and the DON stated residents should be allowed to choose to store leftovers.
Surveyors found that medications on two medication carts were not managed according to labeling and storage requirements. On one cart, opened bottles of Latanoprost and Rocklatan ophthalmic drops lacked opened dates, despite manufacturer directions limiting use to six weeks after opening. On another cart, Pyridium tablets and Dorzolamide ophthalmic drops were discovered past their expiration dates. The assigned nurse reported that nurses are responsible for checking carts for expired medications and dating eye drops when opened but acknowledged she had not checked expiration dates on the carts, and the DON confirmed that these responsibilities and expectations were not met.
The facility did not include the care needs of a resident with a port-a-cath or the related staff training and competency requirements in its facility-wide assessment, despite having updated the document to reflect other service changes. The assessment stated that staff education and competencies were completed for resident care needs but omitted port-a-cath care. A resident had a port-a-cath placed during a prior hospitalization, and at the time of survey this was the only resident with such a device. The DON confirmed nursing staff had not received training or competency checks for port-a-cath care, and the Administrator, responsible for updating the assessment, acknowledged being unaware of this lack of education.
A cognitively impaired resident with Lewy body dementia and known wandering and rummaging behaviors accessed an unlocked drawer in an unattended receptionist’s desk in a lobby common area, obtained a loose OTC cold and flu gel capsule containing acetaminophen, dextromethorphan, and phenylephrine, and ingested it before staff could intervene. Staff reported that residents frequently used the lobby, that there was no system for continuous monitoring in this area, and that the resident was difficult to redirect when wandering and rummaging. After ingestion, the resident became drowsy and lethargic and was evaluated in the ED for altered mental status. The DON and Administrator acknowledged that the resident should have been supervised and kept free from hazards and that unlocked drawers in the lobby had not previously been considered a potential hazard.
The facility failed to ensure 8 consecutive hours of RN coverage daily for 13 days due to unreliable RN Weekend Supervisor staffing. The DON worked additional hours as a staff nurse on some days, but these were not recorded due to his salaried status. A new RN Weekend Supervisor was hired to address the issue.
A resident with high blood pressure and cognitive impairment did not receive the ordered Midodrine medication six times in one month when blood pressure readings indicated it was needed. Medication Aides failed to notify the nurse to administer the PRN medication, and a nurse was unaware of the order. The Consulting Pharmacist noted the missed opportunities to administer the medication, and the DON expected staff to follow orders to prevent negative outcomes.
Two incidents of resident-to-resident abuse occurred in the facility. In the first, a cognitively impaired resident attempted to take items from another resident, leading to a physical altercation. In the second, a resident entered another's room and was slapped. Both incidents highlight the facility's failure to manage residents with behavioral issues and cognitive impairments.
A resident with schizoaffective disorder and a traumatic brain injury was involved in an altercation and sent to the hospital for evaluation. Despite being cleared as safe to return, the facility refused to readmit him, citing behavioral concerns. The ADON and hospital Case Manager had conflicting accounts, and the resident's representative faced challenges in providing care at home. The facility's failure to adhere to the bed-hold policy and ensure continuity of care constitutes a deficiency.
The facility failed to clarify a physician's order for a topical medication, leading to inconsistent dosing for a resident with osteoarthritis. Additionally, a lidocaine patch was not removed as ordered, and a resident received an incorrect dose of Vitamin D3 due to a pharmacy delay. Staff interviews revealed lapses in following the five rights of drug administration.
A resident with a stage IV sacral pressure ulcer and dementia had her urinary catheter tubing unsecured, leading to potential tension or trauma. Despite the resident's request for a stabilizing device, it was not provided until observed by the Wound Treatment Nurse. Staff interviews revealed a lack of consistent understanding of the facility's policy requiring catheter stabilization.
A resident with end-stage renal disease did not have their dialysis dressing removed as per physician's orders, leading to potential complications. Despite clear instructions and reminders, the dressing was observed still in place the day after dialysis. Nurse #5 did not remove the dressing, citing a lack of awareness of the order, which was documented in the MAR. The Dialysis Nurse and DON had communicated the importance of timely dressing removal to prevent access site damage.
A medication error rate of 8% was identified in an LTC facility when a nurse prepared two tablets of Ciprofloxacin instead of one and intended to crush Protonix despite 'do not crush' instructions. The resident involved was severely cognitively impaired, and the errors were observed during medication administration preparation. The DON acknowledged the nurse's failure to follow the complete order and special instructions.
Expired medications were found on two medication carts during a survey. An LPN admitted to overlooking expired Geri-dryl, Liquid Tylenol, and Simethicone, which were not administered that day. The DON confirmed that night shift nurses were responsible for checking for expired medications.
A facility failed to accurately document the removal of a Lidocaine patch and a fall mat for a resident, and the removal of a dressing for another resident post-dialysis. Staff signed off on tasks that were not completed, leading to inaccurate medical records. The DON acknowledged the deficiency and had previously addressed similar concerns with staff.
Two nurses failed to follow Enhanced Barrier Precautions (EBP) by not wearing gowns during high-contact care activities for residents with tracheostomy and wound care. Despite EBP signage indicating the need for gowns, one nurse did not wear a gown during tracheostomy care, and another forgot to wear a gown during wound dressing changes.
Failure to Maintain Accountability and Documentation for Controlled Medications
Penalty
Summary
Surveyors identified a deficiency in the facility’s pharmaceutical services related to the accounting and handling of controlled medications for nine residents. For multiple residents with active or time-limited PRN orders for controlled substances such as lorazepam, hydrocodone-acetaminophen, oxycodone, oxycodone-acetaminophen, and tramadol, pharmacy packing slips and proof-of-delivery records showed that controlled medications were dispensed and delivered to the facility. However, for these deliveries, the facility frequently lacked required documentation, including missing declining count sheets (narcotic inventory logs) and incomplete or absent nurse signatures on delivery receipts. In one case, a resident had an order for lorazepam 0.5 mg every 24 hours as needed for anxiety for 14 days, with 14 tablets delivered, but there was no declining count sheet, no narcotic book entry, and no MAR documentation that any doses were administered after delivery. For several other residents, similar documentation gaps were found. Residents with active orders for hydrocodone-acetaminophen, oxycodone, oxycodone-acetaminophen, and tramadol had controlled medications delivered in quantities ranging from 30 to 90 tablets, but there were no corresponding declining count sheets located for any of these medications. In many instances, the delivery receipts were signed by only one nurse, often the same nurse, or had no nurse signature at all, despite the presence of two signature lines intended for verification by two nurses. The DON later confirmed that declining count sheets were missing for nine residents whose controlled medications had been delivered during the review period, and that the missing lorazepam tablets for one resident had not been returned to the pharmacy and were not documented as administered. Interviews with facility and pharmacy staff further described how these documentation failures and lack of oversight contributed to the deficiency. The DON explained that prior to the discovery of missing medications, the process for receiving controlled drugs involved whichever nurse was available distributing medications from the delivery tote to the medication carts and signing the delivery sheet, without consistent second-nurse verification. The DON also stated she did not verify that medications documented on delivery sheets were actually present on the carts and did not identify the absence of declining count sheets until missing medications were reported. The Unit Manager reported that she did not audit controlled medications and believed the DON was responsible. The Consultant Pharmacist stated she did not conduct controlled medication cart audits and believed the pharmacy’s Nurse Consultant did random checks, while the Pharmacy Nurse Consultant stated he only verified that narcotic boxes were locked and did not review controlled medications or declining count sheets. The Pharmacy Director confirmed that the pharmacy did not track discontinued controlled medication orders and relied on the facility to remove and return discontinued medications, which did not occur for at least one resident’s discontinued lorazepam order.
Ongoing Administration of Metolazone Outside Ordered BP Parameters Despite Pharmacy Reviews
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a licensed pharmacist’s monthly drug regimen review and subsequent nursing actions prevented ongoing administration of a diuretic medication outside ordered parameters for one resident. The resident was admitted with diagnoses including heart failure, hypertension, and kidney disease and had a physician’s order for Metolazone 5 mg to be given orally on Mondays, Wednesdays, and Fridays for edema, with instructions to hold the medication if the systolic blood pressure was less than 110 or the diastolic blood pressure was less than 60. Review of the September Medication Administration Record (MAR) showed that Metolazone was administered multiple times by one nurse when the resident’s blood pressure readings were below the ordered parameters, including systolic readings under 110 and diastolic readings under 60. In October and November, the Consultant Pharmacist identified that Metolazone had been administered outside the ordered blood pressure parameters and documented this in monthly medication regimen review reports sent to the DON. The October review noted that the resident had received Metolazone outside parameters on several occasions in September and October, and the November review again informed the DON that the resident continued to receive Metolazone outside the ordered parameters. On both reports, the Unit Manager documented that nursing staff had been educated, but did not specify whether the nurse who administered the medication in error received this education or what specific education was provided. Despite these pharmacist reports, MARs for October and November showed that the same nurse continued to administer Metolazone on multiple dates when the resident’s blood pressure readings were below the ordered hold parameters. In December and January, the Consultant Pharmacist’s monthly medication regimen reviews did not include any recommendations regarding the resident’s Metolazone, even though the MARs for those months showed that the same nurse continued to administer the medication on numerous dates when the resident’s blood pressure readings remained below the ordered parameters. The Consultant Pharmacist later stated that she did not address Metolazone in those months and that this was missed, and she typically did not go back to review prior recommendations. The DON stated that she and the Unit Manager shared responsibility for reviewing and acting on the pharmacy reports and that the Metolazone issue was not reviewed in December or January to ensure the medication was being held per parameters. The nurse who administered the medication stated she was new, misunderstood the hold parameters as applying only if both systolic and diastolic pressures were below 110/60, and was not aware of the medication error until it was brought to her attention during the survey, despite being consistently assigned to the resident and administering Metolazone in this manner since September. This sequence of events shows that the facility did not act effectively on the Consultant Pharmacist’s October and November findings and that the Consultant Pharmacist did not continue to identify and address the ongoing issue in December and January, resulting in the resident continuing to receive Metolazone outside the physician-ordered blood pressure parameters over multiple months.
Failure to Follow Blood Pressure Parameters for Metolazone Administration
Penalty
Summary
Surveyors identified a deficiency in which the facility failed to ensure a resident was free from significant medication errors related to administration of Metolazone, a diuretic prescribed with specific blood pressure hold parameters. The physician’s order dated 9/5/25 directed that Metolazone 5 mg be given orally on Monday, Wednesday, and Friday for edema, with instructions to hold the dose if the systolic blood pressure was less than 110 or the diastolic blood pressure was less than 60. Despite these parameters, review of the Medication Administration Records (MARs) from September 2025 through February 2026 showed that the medication was repeatedly administered when the resident’s blood pressure readings were outside the ordered limits. The resident involved was admitted with diagnoses including heart failure, hypertension, and kidney disease, and received diuretic medications. MAR review revealed that Metolazone was documented as given on multiple dates over several months when either the systolic blood pressure was below 110 or the diastolic blood pressure was below 60. These administrations occurred on numerous specific dates in September, October, November, and December 2025, as well as January and February 2026, totaling 57 doses given contrary to the ordered hold parameters. Progress notes from 9/10/25 through 2/11/26 contained no documentation of any change in the resident’s condition during this period. During interviews, the nurse who administered the medication on all of the identified dates acknowledged giving Metolazone despite the blood pressure readings and stated she misunderstood the order, believing the medication should be held only if both systolic and diastolic pressures were below 110/60. The nurse reported she was new and consistently assigned to care for this resident. The resident was observed sitting in a wheelchair, in no distress, and voiced no concerns with care. The Nurse Practitioner confirmed that the order required holding Metolazone if either the systolic was less than 110 or the diastolic was less than 60 and stated she was not aware the medication had been given outside these parameters. The Consultant Pharmacist stated that taking Metolazone when not indicated could cause hypotension and increase fall risk. The Director of Nursing reported she was not aware that Metolazone had continued to be administered outside the ordered parameters and that the resident had no falls and no change in condition.
Failure to Safeguard and Account for Controlled Pain Medications
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from misappropriation of their controlled pain medications and to maintain required controls over these drugs. For nine residents with active orders for narcotic or controlled pain medications (including tramadol, oxycodone, hydrocodone-acetaminophen, and oxycodone-acetaminophen), pharmacy records showed that multiple prescriptions were filled and delivered to the facility, but there were no corresponding declining count sheets or complete delivery documentation. In several instances, delivery receipts were signed by only one nurse instead of two, and in some cases there was no nurse signature at all. The Director of Nursing (DON) later confirmed that the medications for these residents were never entered into the narcotic records and that the declining count sheets were missing. For each of the nine residents, the surveyors verified that controlled medications had been ordered by a practitioner and dispensed by the pharmacy, but the facility lacked the required inventory logs to track receipt and use of these medications. For example, one cognitively intact resident with an order for scheduled tramadol had 30 tablets documented as delivered by the pharmacy, signed as received by a night-shift nurse, but no second nurse signature and no declining count sheet could be found. Another resident with severely impaired cognition and an as-needed oxycodone order had two separate deliveries of 60 tablets each documented by the pharmacy, yet there were no nurse signatures on one delivery sheet and no declining count sheets for either shipment. Similar patterns occurred for residents with diagnoses such as cancer, heart failure, CVA, arthritis, diabetes, renal disease, and deep vein thrombosis, all of whom had active controlled medication orders and documented pharmacy deliveries without corresponding facility inventory records. Interviews and record reviews showed that the facility’s process for handling controlled medication deliveries contributed to the deficiency. The DON stated that when controlled medications were delivered, whichever nurse was available would distribute medications from the delivery tote to the medication carts and sign the delivery sheet, even though the form had two signature lines intended for both the nurse checking in the medications and the nurse receiving them on the cart. The DON acknowledged that two nurses were not consistently signing the delivery sheets, that she did not verify that medications documented as delivered were actually placed on the carts, and that missing medications were not recorded in the narcotic book. An internal audit initiated after one resident’s tramadol could not be located revealed that eight additional residents had missing controlled medications for active orders, and the facility ultimately identified a total of 660 missing controlled tablets for active orders. Staff interviews indicated that a specific medication aide had been acting suspicious, and subsequent drug testing of staff showed that this aide tested positive for the missing medications, coinciding with the period in which the controlled medications and required documentation were absent. Additional interviews with the Chief Nursing Officer, Nurse Consultant, pharmacy director, and nurse practitioners further described how ordering and dispensing practices led to excessive quantities of controlled medications being present on medication carts without adequate tracking. One nurse practitioner reported that during monthly pain assessments she routinely ordered refills for controlled pain medications without first checking with nursing staff to determine if refills were needed, and the pharmacy director stated that the pharmacy would refill controlled medications when orders were received if they had not been filled in a while. These practices resulted in large amounts of controlled medications being stored on the carts. Although facility leadership and pharmacy representatives later described changes to ordering and refill processes, the surveyors noted that the facility-provided corrective action plan could not be validated.
Failure to Obtain Orders and Maintain a Resident’s Port-a-Cath
Penalty
Summary
The deficiency involves the facility’s failure to obtain and implement provider orders for the care and maintenance of a resident’s port-a-cath. The resident, who had a history of traumatic brain injury with a persistent vegetative state and severely impaired decision-making, was admitted with a left chest port-a-cath placed in the hospital for future vascular access. The hospital discharge summary documented that the port-a-cath was initially too immature to use and required 7 to 14 days to heal before use, and later hospital documentation indicated the port-a-cath was available for medication administration and had been flushed with normal saline and heparin prior to discharge back to the facility. Despite this, review of physician orders from the time of port placement through the survey period showed no orders related to accessing or maintaining the port-a-cath, and the resident’s care plan contained no plan of care addressing the device. Surveyor observation confirmed the presence of a left chest port-a-cath, and staff interviews revealed a lack of knowledge and action regarding its management. A nurse stated she did not know if there were orders for the port-a-cath and believed only RNs could access and flush it. The Unit Manager, who handled the resident’s readmission from the hospital, reported she did not realize orders were needed to access and flush the port-a-cath and noted that both nurses who reviewed the readmission orders were LPNs. The DON acknowledged that the resident had a port-a-cath due to poor vascular access, that orders should typically be obtained upon admission for care and maintenance, and that the facility had never accessed or maintained the resident’s port-a-cath since placement. The NP confirmed awareness that the resident had a port-a-cath for IV fluids, medications, and blood draws and stated that such devices are usually usable about two weeks after placement and should be accessed and flushed routinely. The NP acknowledged that the port-a-cath had not been accessed or flushed at the facility since its placement in December 2024 and that no orders had been written for its maintenance. She further stated she assumed the hospital had accessed and flushed the port during the resident’s hospitalizations and had only verbally mentioned ordering special needles to nursing staff without following through with orders or physician discussion. Collectively, these actions and inactions resulted in the absence of physician orders, care planning, and routine maintenance for the resident’s port-a-cath over an extended period.
Failure to Honor Resident Choice for Storage and Reheating of Outside Food
Penalty
Summary
The deficiency involves the facility’s failure to honor residents’ choices regarding storage and reheating of food brought from outside the facility, despite regulatory requirements to promote and facilitate resident self-determination and choice. One resident with acute unspecified protein calorie malnutrition, who was moderately cognitively impaired but independent with eating, reported that she did not like the facility’s food and preferred food from home or local restaurants. She stated that the facility would not allow her to store cooked foods in the refrigerator or have them reheated, and that she had been told such storage was not allowed. Another cognitively intact resident, independent with eating, reported that he previously ordered pizza monthly, ate part of it, and stored the remainder in the refrigerator to be reheated for later meals, but was recently told he could no longer store cooked food or have it reheated, and that staff threw away pizza he had purchased. A third cognitively intact resident with stroke and diabetes stated he did not like the facility’s food and preferred healthy, diabetic foods provided by his family, but was told he could not store cooked foods in the refrigerator or have them reheated, and that personal refrigerators in rooms were not allowed. Surveyors observed a sign on the nourishment room refrigerator stating that no cooked food may be stored and that no stored foods were allowed per facility policy. The Dietary Manager confirmed that the facility’s policy prohibited residents from storing food in the nourishment room refrigerator to prevent potentially hazardous food illnesses, allowing only drinks and nutritional supplements. The RD stated that previously cooked food items could usually be safely stored in the refrigerator for up to three days. The DON stated she expected residents to be allowed to make choices about their food, including storing leftovers for later consumption, while the Administrator confirmed the facility policy not to allow residents to store or reheat food and to discard any cooked foods not eaten within four hours, and that residents were not allowed personal refrigerators in their rooms.
Failure to Discard Expired Medications and Date Opened Ophthalmic Drops on Medication Carts
Penalty
Summary
Surveyors identified a deficiency in the facility’s medication storage and labeling practices on two of six medication carts reviewed. On the 200-hall medication cart #1, an opened bottle of Latanoprost 0.005% ophthalmic drops and an opened bottle of Rocklatan ophthalmic drops were found without any opened dates labeled on the bottles, despite manufacturer instructions that each product may be stored at room temperature for only six weeks after opening before being discarded. On the 200-hall medication cart #2, Pyridium (phenazopyridine) 95 mg tablets and a bottle of Dorzolamide 2% ophthalmic drops were found with expiration dates that had already passed. During interviews, the nurse assigned to both medication carts stated that all nurses were responsible for checking the carts for expired medications and for recording opened dates on eye drops, but acknowledged she had not checked expiration dates on either cart and had not administered the expired medications that day. She also stated she did not open the eye drops on medication cart #1 and that the drops should have been dated when opened. The DON confirmed that the assigned nurse is responsible for checking medication carts for expired medications and ensuring medications with shortened expiration dates are labeled with an opened date, and stated that the expired medications should have been discarded and the eye drops labeled with opened dates.
Failure to Include Port-a-Cath Care and Training in Facility Assessment
Penalty
Summary
The facility failed to ensure its facility-wide assessment identified and addressed the care needs of residents with a port-a-cath and the associated staff training and competencies. The facility assessment, last updated on 9/8/2025, stated that education, training, and competencies had been completed specific to resident care needs, but it did not include training or competency requirements for care of residents with a port-a-cath. The Administrator, who is responsible for updating the facility assessment with input from the DON and other administrative staff, had updated the assessment on 1/1/2026 to reflect a change in therapy providers but did not include the care needs related to port-a-caths, despite knowing that all resident care needs should be reflected in the facility assessment. Resident #1 was admitted to the facility with a port-a-cath that had been placed on 12/18/2024 during a hospitalization for pneumonia. At the time of the survey, the facility had one resident with a port-a-cath. During interviews, the DON confirmed that nursing staff had not received training or competencies regarding port-a-cath care. The Administrator confirmed there was one resident with a port-a-cath and stated he was not aware that nursing staff had not been educated or had competencies checked for providing care to residents with a port-a-cath.
Failure to Supervise Cognitively Impaired Resident and Control Access to Medication in Lobby Area
Penalty
Summary
The deficiency involves the facility’s failure to provide effective supervision and maintain an environment free from accident hazards for a cognitively impaired resident with known wandering and rummaging behaviors. The resident had Lewy body dementia and other significant medical diagnoses, including atrial fibrillation, hypertension, diabetes, COPD, heart failure, thyroid disease, and kidney disease. The resident’s care plan identified risk for cognitive decline related to delirium history and neurocognitive disorder with Lewy body dementia, with an intervention to monitor, document, and report changes in cognitive function. The quarterly MDS documented moderate cognitive impairment and wheelchair use, and staff interviews described a pattern of wandering throughout the facility, entering other residents’ rooms and common areas, and rummaging through belongings, with staff reporting difficulty redirecting the resident. On the day of the incident, the resident was in the lobby area, which is an open common area with television and seating where residents can freely sit and propel their wheelchairs. The receptionist’s desk is located in this lobby area near the facility entrance. The Unit Coordinator reported that the receptionist left her desk unattended, with an unlocked desk drawer containing a loose over-the-counter cold and flu gel capsule. As the receptionist returned to the desk, she observed from across the room that the resident had opened the unlocked drawer, found the loose gel capsule, and ingested it before staff could intervene. The Unit Coordinator stated that residents were frequently in the front common area and that most residents did not wander or go into things, but there was no system in place to ensure continuous monitoring of residents in that area. Following ingestion of the cold and flu gel capsule containing acetaminophen, dextromethorphan, and phenylephrine, the resident initially appeared to be okay but then became drowsy and lethargic, according to the Unit Coordinator and Weekend Supervisor. A nursing note documented that the resident went through the unattended receptionist’s desk, found the capsule, and ingested its contents. Another nursing note later documented that the resident was lethargic and not responding after ingesting the medication and was sent to the emergency department for evaluation of altered mental status. The emergency department record indicated the resident arrived with stable vital signs and a history that her altered mental status began after ingesting the over-the-counter cold and flu medication taken from the receptionist’s desk drawer. The DON and Administrator both acknowledged that the resident should have been supervised and kept free from hazards, and that prior to this incident the facility had not considered unlocked drawers in the lobby area as a potential hazard for cognitively impaired residents, and there was no system to ensure continuous monitoring of residents in common areas, including the lobby.
Failure to Provide Consistent RN Coverage
Penalty
Summary
The facility failed to provide 8 consecutive hours of Registered Nurse (RN) coverage a day, 7 days a week for 13 of 139 days reviewed. The Payroll Based Journal (PBJ) Staffing Data Report for Fiscal Year - Quarter 2, 2024, and Quarter 3, 2024, documented several days where there was no RN coverage. Specifically, there was no RN coverage on multiple dates across January, February, March, April, and May 2024. The Director of Nursing (DON) worked as a staff nurse on some of these days after fulfilling his full-time obligations as the DON, but these hours were not reported due to his salaried status and not punching the time clock. Interviews with the facility's Administrator, Nursing Scheduler/Payroll Manager, and the DON revealed that the staffing issues were primarily due to the unreliability of the RN Weekend Supervisor. The DON confirmed that he worked additional hours as a staff nurse on certain days, but these were not reflected in the PBJ report. The facility had since hired a new RN Weekend Supervisor, which reportedly resolved the recent staffing issues, but the deficiency occurred due to the lack of consistent RN coverage on the specified dates.
Failure to Administer Hypotensive Medication as Ordered
Penalty
Summary
The facility failed to administer the physician-ordered hypotensive medication, Midodrine, to a resident with high blood pressure and Vitamin D deficiency, six times in one month. The resident was moderately cognitively impaired and had specific orders for Midodrine to be given when blood pressure was less than 110/60 mm/Hg. Despite the Metoprolol Tartrate being held due to low blood pressure readings, the Midodrine was not administered as required. This was evidenced by the absence of nursing initials or checkmarks on the Medication Administration Record (MAR) for the days in question. Interviews with staff revealed that Medication Aides were not allowed to administer PRN medications and failed to notify the charge nurse when the resident's blood pressure was within the parameters for Midodrine administration. Nurse #6 confirmed not administering the medication due to unawareness of the order. The Consulting Pharmacist indicated that the medication should have been given to prevent further drops in blood pressure. The Director of Nursing expected staff to follow medication orders and acknowledged that failure to do so could result in negative outcomes for the resident.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect residents from physical abuse, as evidenced by two incidents involving resident-to-resident altercations. In the first incident, a resident with severe cognitive impairment attempted to take belongings from another resident's hat, leading to a physical confrontation. The second resident, who had a history of behavioral issues and was using a wheelchair, responded by shaking the first resident and attempting to run him over with the wheelchair. Despite the altercation, the first resident did not sustain any injuries. The facility's staff, including the Unit Manager and the Director of Nursing (DON), were not fully aware of the incident's details or the residents involved until after it occurred. In another incident, a resident with severe cognitive impairment entered another resident's room, resulting in the latter slapping the intruder on the cheek. The resident who was slapped experienced mild redness, which resolved quickly. The facility's staff, including a Medication Aide and the DON, were informed of the incident after it occurred. The resident who slapped the other had no prior history of physical aggression, and the incident was considered isolated by the staff. Both incidents highlight the facility's failure to adequately monitor and manage residents with known behavioral issues and cognitive impairments. The care plans for the involved residents did not effectively address their behavioral problems, and staff interventions were insufficient to prevent the altercations. The facility's response to these incidents was reactive rather than proactive, indicating a deficiency in protecting residents from abuse.
Facility Fails to Readmit Resident After Hospital Clearance
Penalty
Summary
The facility failed to permit a resident to return after hospitalization, violating the bed-hold policy. Resident #84, who had schizoaffective disorder and a traumatic brain injury, was involved in a resident-to-resident altercation and was sent to the hospital for evaluation. Despite being cleared by the hospital as safe to return, the facility refused to readmit him, citing concerns about his behavior. The Assistant Director of Nursing (ADON) and the hospital Case Manager had conflicting accounts, with the ADON claiming she might have told the hospital that the resident could not return, while the Case Manager confirmed the resident was safe for discharge. The Psychiatric provider confirmed that the only order given was to send the resident to the hospital for evaluation, and no order was given to refuse readmission. The Director of Nursing (DON) acknowledged the facility's obligation to hold the resident's bed for 30 days and to readmit him once cleared by the hospital. However, the resident was not readmitted, and the facility's Social Worker provided documentation to the resident's representative to seek placement elsewhere. The resident's representative expressed difficulties in caring for the resident at home and financial strain due to the facility's refusal to readmit him. The Administrator was unaware of the ADON's decision and believed it was a judgment call due to staff fears. The facility's failure to readmit the resident after hospital clearance constitutes a deficiency in adhering to the bed-hold policy and ensuring continuity of care.
Medication Administration Deficiencies
Penalty
Summary
The facility failed to clarify a physician's order for a topical medication for a resident with osteoarthritis, resulting in the medication being administered without a specified dose for 26 days. The order for Diclofenac Sodium External 1% did not indicate the number of grams to be applied, leading to inconsistent application by various nursing staff and medication aides. Interviews with the staff revealed that they applied varying amounts of the ointment without measuring, and none of them sought clarification of the order until a medication pass observation prompted a review and correction of the order. Another deficiency involved the failure to follow a physician's order for the removal of a lidocaine patch after 12 hours for a resident with pain. The patch was left on overnight, contrary to the order, and was only removed the following morning by a medication aide. The nurse responsible admitted to signing off on the removal without actually performing it, citing being busy as the reason for the oversight. The nurse practitioner confirmed that leaving the patch on longer than ordered could lead to skin irritation, although no irritation was observed in this instance. The facility also failed to administer the correct dose of Vitamin D3 to a resident due to a delay in receiving the correct medication from the pharmacy. The medication aides administered a lower dose than ordered, mistakenly believing it was the correct one. The consulting pharmacist noted that while the lower dose would not cause harm, the aides should have verified the medication label and informed the nurse of the discrepancy. The director of nursing emphasized the importance of adhering to the five rights of drug administration, which includes ensuring the right dose is given.
Failure to Secure Urinary Catheter Tubing
Penalty
Summary
The facility failed to secure a resident's indwelling urinary catheter tubing, which could prevent tension or trauma. The resident, who was admitted with diagnoses including a stage IV sacral pressure ulcer and dementia, was observed with her urinary catheter tubing hanging off the side of the bed without being secured. The catheter bag was hooked to the lower side of the bed, and the resident reported that she had requested a stabilizing device but had not received one. The Wound Treatment Nurse confirmed that the tubing should have been secured and proceeded to attach a stabilizing device to the resident's thigh. Interviews with staff revealed inconsistencies in understanding and implementing the facility's policy regarding catheter stabilization. Nurse #2 incorrectly stated that residents did not need a stabilizing device unless they wanted one, while the Assistant Director of Nursing and the Administrator both confirmed that the facility policy required a stabilizing device for all residents with an indwelling urinary catheter. This discrepancy in staff understanding and adherence to policy contributed to the deficiency observed during the survey.
Failure to Follow Dialysis Dressing Removal Orders
Penalty
Summary
The facility failed to follow the physician's orders regarding the care of a resident who required dialysis services. The resident, who was moderately cognitively impaired and diagnosed with end-stage renal disease, had a physician's order to have the dressing on their arterial venous fistula removed approximately one hour after returning from dialysis. This order was intended to prevent potential damage to the access site and to monitor for bleeding. However, the dressing was not removed as ordered, and it was observed still in place the following day. Nurse #5, who was responsible for the resident's care, did not remove the dressing, claiming there was no order to do so, despite the order being documented in the medication administration record (MAR). The Dialysis Nurse had previously communicated the importance of removing the dressing to prevent complications, and the Director of Nursing had addressed this issue with the staff, ensuring an order was in place to remind them. Despite these measures, the dressing remained on the resident's access site, which could potentially cause complications. The failure to remove the dressing as ordered was confirmed through interviews with the nursing staff and observations of the resident, highlighting a lapse in following established care protocols for dialysis patients.
Medication Error Rate Exceeds 5% Due to Incorrect Dosage and Crushing Instructions
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, as evidenced by two medication errors out of 25 opportunities, resulting in an 8% error rate. The errors were observed during a medication administration preparation for a resident who was severely cognitively impaired. Nurse #7 prepared medications for the resident, including Allopurinol, Ciprofloxacin, Finasteride, Haldol, Protonix, Seroquel, Flomax, and aspirin. However, Nurse #7 incorrectly prepared two tablets of Ciprofloxacin instead of one and intended to crush all medications, including Protonix, which had a 'do not crush' instruction. During the observation, Nurse #7 admitted to not noticing the 'do not crush' instruction on the Protonix dispensing card and had been crushing it regularly. The Consulting Pharmacist later confirmed that administering more than the ordered dose of Ciprofloxacin could cause stomach discomfort, and crushing Protonix would make it less effective. The Director of Nursing acknowledged that Nurse #7 should have read the entire order and followed special instructions, such as 'do not crush,' to prevent such errors.
Expired Medications Found on Medication Carts
Penalty
Summary
The facility failed to discard expired opened multidose medications on two of the four medication carts reviewed. During an observation of the 300 Hall medication cart, an opened bottle of Geri-dryl with an expiration date of 10/24 was found. Nurse #5, who was present during the observation, admitted that the night shift nurses were responsible for checking the medication carts for expired medications, but she also checked her cart and overlooked the expired Geri-dryl. She confirmed that she did not administer this medication on the day of the observation. Similarly, an observation of the 400 Hall medication cart revealed an opened bottle of Liquid Tylenol with an expiration date of 09/24/24 and an opened bottle of Simethicone with an expiration date of 08/24/24. Nurse #5 again acknowledged that the night shift nurses were supposed to check for expired medications, but she missed the expired Liquid Tylenol and Simethicone. She confirmed that neither of these medications was administered on the day of the observation. The Director of Nursing stated that it was the facility's responsibility to ensure that all medications on the carts were not expired and reiterated that the night shift nurses were tasked with checking for expired medications due to their increased availability during downtime.
Inaccurate Documentation of Medical Orders
Penalty
Summary
The facility inaccurately documented the removal of a Lidocaine patch and the presence of a fall mat for a resident during a medication pass. The resident, who was admitted with diagnoses including stroke with left side weakness and pain, had a physician's order for a Lidocaine patch to be applied daily and removed after 12 hours. However, during a medication pass, it was observed that the patch from the previous day was still on the resident's back, despite being signed off as removed by a nurse. The nurse admitted to signing off the removal without actually performing the task due to being busy. Additionally, the medication aide signed off on the presence of a fall mat, which was not in place, admitting to clicking off the task in error. Another resident, who was admitted with end-stage renal disease and dependent on dialysis, had a physician's order to remove the dressing from the dialysis access site after each treatment. The order was signed off as completed by a nurse, but the dressing was found still in place the following day. The nurse claimed there was no order to remove the dressing, but upon review, confirmed the order existed and admitted to signing off without removing the dressing. The Director of Nursing (DON) expressed expectations that staff should follow physician orders accurately and document tasks only after completion. The DON acknowledged previous concerns about the removal of dressings post-dialysis and had implemented an order to remind staff of this requirement. The inaccurate documentation by the nursing staff was identified as a deficiency in maintaining professional standards for medical records.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
Facility staff failed to implement their Enhanced Barrier Precautions (EBP) policy when two nurses did not apply gowns before providing care to residents under EBP. Nurse #3 was observed providing tracheostomy care to Resident #40 without wearing a gown, despite the EBP sign on the resident's door indicating that a gown was necessary for high-contact care activities. Nurse #3 initially believed a gown was not required for tracheostomy care until he read the EBP sign and acknowledged the need for a gown. Similarly, Wound Nurse #1 was observed completing wound dressing changes for Resident #12 without wearing a gown, even though the EBP signage on the resident's door instructed staff to wear a gown and gloves during high-contact care activities. Wound Nurse #1 admitted to forgetting to put on a gown, despite being aware of the EBP requirements. The Assistant Director of Nursing, who also serves as the facility's Infection Control Preventionist, confirmed that both nurses should have worn gowns while providing care to the residents.
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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