The Greens At Pinehurst Rehabilitation & Living Ce
Inspection history, citations, penalties and survey trends for this long-term care facility in Pinehurst, North Carolina.
- Location
- 205 Rattlesnake Trail, Pinehurst, North Carolina 28374
- CMS Provider Number
- 345177
- Inspections on file
- 24
- Latest survey
- March 19, 2026
- Citations (last 12 mo.)
- 9
Citation history
Health deficiencies cited at The Greens At Pinehurst Rehabilitation & Living Ce during CMS and state inspections, most recent first.
The facility failed to accurately code MDS assessments for medications for two residents. One resident with bladder dysfunction and urinary retention was coded on a quarterly MDS as receiving an antibiotic during a seven-day assessment period, even though the MAR showed no antibiotic administration during that time, which the MDS coordinator later confirmed as an error. Another resident with dementia, psychotic disturbance, and PTSD was ordered Hydroxyzine 12.5 mg twice daily for anxiety, and the MAR showed it was given; however, the MDS nurse coded this as an antianxiety medication on the MDS, later acknowledging that Hydroxyzine is an antihistamine and that the antianxiety classification on the assessment was incorrect.
A resident with major depressive disorder, generalized anxiety disorder, and PTSD was admitted with a short‑term Level II PASRR approval that had a defined expiration date. The admission MDS showed the resident had not been evaluated and determined to have a serious mental illness, intellectual disability, or related condition under a current Level II PASRR. Facility records contained no evidence that staff submitted a referral to obtain a new Level II PASRR evaluation before the prior approval expired. In interviews, the SW acknowledged that the Level II PASRR had expired without renewal due to an oversight, and the Administrator stated that PASRR evaluations were expected to be monitored and updated before expiration.
A resident with hypertension and constipation had physician orders for Metoprolol and MiraLax via G-tube twice daily, scheduled for administration at 9:00 AM. On one occasion, an agency nurse fell behind on the morning med pass and did not administer these medications until around noon, outside the facility’s one-hour before/after scheduled time requirement. The nurse did not request assistance despite prior instructions for agency staff to do so if they were falling behind. The DON and Medical Director confirmed that medications were required to be given within the established one-hour window and that this expectation was not met, although the resident showed no clinical ill effects.
A resident with dysphagia, gastrostomy status, and aphasia following a stroke was receiving continuous enteral feeding and scheduled water flushes via G-tube. A nurse administered medications through the G-tube using a syringe she had noticed was discolored, then rinsed it with water, separated the syringe and plunger, and stored them in a plastic bag without allowing them to air dry. Later observation found the syringe tip and lower barrel coated with thick, crusted yellow material and the storage bag containing water droplets with pooling. The DON stated the syringe should have been washed, allowed to dry before storage in a dry bag, and that a stained syringe should have been discarded and replaced. This practice had the potential to cause bacterial growth and contamination.
Surveyors found that the ADON failed to follow infection control policies for hand hygiene and glove use while performing wound care on two residents under enhanced barrier precautions for wounds and, for one resident, an indwelling urinary catheter. The ADON did not perform hand hygiene before donning gloves, did not change gloves or perform hand hygiene between removing soiled dressings and applying clean dressings, and placed soiled dressings and used gauze on clean barriers next to unused supplies. She also exited a room wearing a gown, retrieved supplies from the hallway, reentered without hand hygiene, and continued wound care without appropriate glove changes, contrary to facility policies requiring hand hygiene at specified points and proper handling of soiled and clean items.
The facility failed to ensure residents and their representatives were routinely invited to participate in care planning. A cognitively intact resident and the resident’s representative were not included in multiple care plan meetings, and the resident reported never being invited or informed about such meetings despite wishing to participate. Another resident with dementia and multiple comorbidities had a representative who received only one invitation to a care plan conference and was unaware that regular care plan reviews should occur. The SW reported she had only been organizing 72‑hour post‑admission or concern‑driven meetings, was unaware she was responsible for scheduling routine quarterly and annual care plan conferences based on the MDS calendar, and confirmed these had not been completed for all residents. The administrator acknowledged learning that required quarterly and annual care plan meetings and invitations for residents and representatives had not been carried out as expected.
A dependent resident with a contracted hand and reduced mobility, care planned as needing assistance with personal hygiene and documented on MDS as dependent for personal hygiene, did not receive appropriate fingernail care. Over multiple observations, the resident’s fingernails remained long, jagged, and soiled, despite the resident’s stated preference for short nails and reports that long nails caused discomfort by stabbing into the contracted hand. Bath and skin review documentation addressed only toenails, and weekly skin assessments lacked fingernail documentation. The assigned NA acknowledged not providing or offering nail care during a bed bath, and nursing staff interviews confirmed that nail care oversight during weekly skin assessments and routine hygiene was not carried out for this resident.
A resident with intractable epilepsy and moderately impaired cognition had physician orders and a care plan directing scheduled anti-seizure medications via G-tube to be given at specific morning times. On one morning, an agency nurse fell behind on medication administration and did not give the resident’s 8:00 AM and 9:00 AM anti-seizure doses until shortly after noon, 3–4 hours late and outside the facility’s one-hour before/after policy window, and did not request assistance despite prior instruction that agency staff should do so if behind. Review of the MAR, interviews with the nurse, DON, and Medical Director, and the resident’s record confirmed the delay and that the medications were not administered as ordered, although the resident showed no documented clinical ill effects.
The facility failed to accurately post and maintain daily nurse staffing information, with multiple days where the posted counts of NAs, an RN, and LPNs did not match the actual staffing schedule, including miscounts and misclassification of an RN as an LPN. The Scheduler acknowledged not updating postings when staff called out, did not show, or when coverage staff arrived. On at least one observed day, the daily staffing sheet in the reception area was not current, displaying an outdated date instead of the day’s staffing, while the Scheduler and DON each believed the other had ensured proper posting, and leadership later suggested the sheet may have been removed and not replaced.
The facility failed to date leftover food items in the dry goods storage area and walk-in cooler, as observed during a survey. Issues included undated corn flakes, brown sugar, sliced cheese, sliced ham, and cooked mixed vegetables. Staff interviews revealed a lack of adherence to proper food storage protocols, with the new Dietary Manager acknowledging responsibility for ensuring correct dating and storage.
The facility failed to accurately code MDS assessments for falls for three residents. One resident with vascular dementia had a fall with a minor injury that was not recorded. Another resident with a history of stroke and repeated falls had multiple falls, but only one was recorded. A third resident with dementia had two falls without injuries, which were not reflected in the assessments. The MDS Coordinator confirmed these were oversights.
Expired Latanoprost eye drops were found in a medication cart during an observation at an LTC facility. Nurse #1 confirmed the medications were expired and removed them. The DON stated that nurses are responsible for checking expiration dates, but there was no set schedule for unit managers to do so. The facility Pharmacist visits bi-monthly to check carts but did not recall which carts were reviewed last.
The facility did not ensure that NAs received their required annual Dementia training, affecting four NAs who had not been trained since June 2023. The DON and Administrator acknowledged the oversight, which was attributed to the SDC's medical leave. The DON confirmed the training should be completed yearly, and the Administrator expected it to be done annually.
Inaccurate MDS Medication Coding for Two Residents
Penalty
Summary
The facility failed to ensure accurate coding of the Minimum Data Set (MDS) assessments for medications for two residents. For one resident with bladder dysfunction and urinary retention, review of the Medication Administration Record (MAR) for a specified seven-day period showed that no antibiotic medications were administered. However, the quarterly MDS assessment for that same assessment period was coded to indicate the resident had received an antibiotic. Upon review of the MDS and MAR, the MDS Coordinator confirmed that the antibiotic entry on the MDS was incorrect and that the resident had not received an antibiotic during the assessment window. For another resident with dementia with psychotic disturbance and PTSD, physician orders directed administration of Hydroxyzine 12.5 mg twice daily for anxiety, and the MAR confirmed the medication was given as ordered throughout the month reviewed. The quarterly MDS assessment, completed by an MDS nurse, documented that the resident was receiving medications from the antianxiety drug classification and included indications for antianxiety use. During interview, the MDS nurse stated the resident was not ordered any medications classified as antianxiety drugs and acknowledged she had coded the resident as receiving antianxiety medications based on the Hydroxyzine order, being unsure of its drug class. After reviewing medication information, she confirmed Hydroxyzine is classified as an antihistamine and acknowledged that coding it as an antianxiety medication on the MDS was an error.
Failure to Renew Expired Level II PASRR Authorization
Penalty
Summary
The facility failed to obtain a new Level II Preadmission Screening and Resident Review (PASRR) evaluation after the expiration of a short‑term approval for nursing home placement for one resident. The resident was admitted with diagnoses including major depressive disorder, generalized anxiety disorder, and post‑traumatic stress disorder, and the admission MDS indicated the resident had not been evaluated by a Level II PASRR and determined to have a serious mental illness, intellectual disability, or related condition. Record review showed the resident was admitted with a Level II PASRR for short‑term admission that had a specific issuance and expiration date, but there was no documentation that the facility submitted a referral for another Level II PASRR evaluation to extend approval beyond the expiration date. In interviews, the Social Worker confirmed that the resident’s Level II PASRR for short‑term admission had expired and acknowledged that she had not submitted a request for another Level II PASRR evaluation, describing the lapse as an oversight that had fallen through the cracks and stating that a new evaluation should have been requested before the temporary one expired. The Administrator stated that she expected PASRR evaluations to be monitored and kept up to date and acknowledged that a review for this resident should have been requested before the expiration date.
Late Administration of Scheduled Medications Outside Required Time Frame
Penalty
Summary
The deficiency involves the facility’s failure to administer scheduled medications as ordered by the physician and within the facility’s required time frame for one resident. The resident was admitted with diagnoses including hypertension and constipation and had active physician orders for Metoprolol Tartrate 25 mg via G-tube twice daily for hypertension, with parameters to hold for heart rate less than 65 or systolic blood pressure less than 100, and MiraLax 17 gm/scoop via G-tube twice daily for constipation. The March 2026 MAR showed both Metoprolol and MiraLax were scheduled for 9:00 AM but were not administered until 12:07 PM on a specific date, outside the facility’s accepted window of one hour before or one hour after the scheduled time. During interview, the nurse who administered the medications stated he was an agency nurse working intermittently at the facility and reported that he fell behind on morning medication administration and did not give the resident’s morning medications until noon. He acknowledged that he did not request assistance to ensure medications were given on time. The DON stated that medications were required to be administered on time, that agency staff had been instructed to request assistance if they fell behind, and that medications should be given within one hour before or after the scheduled time. The Medical Director confirmed that the resident experienced no ill effects and that vital signs remained within normal limits, and he acknowledged the facility’s requirement that medications be administered within the one-hour window and his expectation that staff follow this policy.
Improper Cleaning and Storage of G-Tube Syringe
Penalty
Summary
The deficiency involves the facility’s failure to properly clean and dry a G-tube syringe before storage for a resident receiving enteral nutrition and medications. The resident had diagnoses including unspecified dysphagia, gastrostomy status, and aphasia following a stroke, and received more than half of her total calories from enteral feedings. Active orders included continuous tube feeding at 72 ml/hr over 20 hours with water flushes every 4 hours. Review of the MAR showed that a nurse administered medications via the G-tube in the morning. Later that morning, surveyors observed the resident’s G-tube flush syringe stored in a plastic bag hanging from the feeding pump pole, labeled as changed at midnight. The syringe was separated from the plunger, but the elongated tip and lower third of the barrel contained thick, crusted yellow material, and the storage bag contained water droplets with pooling at the bottom. During interview, the nurse who had administered the medications acknowledged that she had observed the syringe was discolored when she used it earlier. She stated that some medications could stain syringes and reported that she rinsed the syringe with water after use but had no supplies to scrub it. She explained that she separated the syringe and plunger and placed them into the storage bag after rinsing, and she was not aware that the syringe and plunger should be allowed to air dry before being placed into a clean, dry bag. The DON later stated that the syringe should have been washed, the plunger removed to allow drying before storage in a dry bag to prevent bacterial growth, and that the stained syringe should have been discarded and replaced, with G-tube syringes routinely replaced on night shift. The report states that this deficient practice had the potential to cause bacterial growth and contamination.
Failure to Follow Hand Hygiene and Glove Protocols During Wound Care
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program related to hand hygiene and glove use during wound care. The facility’s policy required alcohol-based hand rub as the preferred method of hand hygiene when hands are not visibly soiled, and specified hand hygiene before donning gloves, before handling clean or soiled dressings, after handling used dressings or contaminated equipment, and after removing gloves. The enhanced barrier precautions protocol required staff to wear gloves and a gown for high-contact resident activities such as wound care and to perform hand hygiene before and after leaving the resident’s room. During wound care for a resident on enhanced barrier precautions for wounds and an indwelling urinary catheter, the Assistant Director of Nursing (ADON) donned a gown and gloves before entering the room and placed a clean towel as a barrier on the bedside table, then placed clean supplies on it. She removed a soiled dressing from the resident’s right foot and placed it on the clean barrier next to unused supplies, did not remove gloves or perform hand hygiene before cleaning the wound, and then opened and applied collagen and a bordered dressing without changing gloves or performing hand hygiene. She then removed a soiled sacral dressing, placed it on the bedside barrier, cleaned the sacral wound, and again opened and applied collagen and a bordered dressing without changing gloves or performing hand hygiene between handling soiled items and clean supplies. In a separate observation of wound care for another resident on enhanced barrier precautions for a wound, the ADON donned a gown and gloves without performing hand hygiene before entering the room. She placed a clean towel and clean wound care supplies on the bedside table, repositioned the resident, removed a soiled sacral dressing and left it on the bed, then cleaned the wound and placed used gauze on the towel next to clean supplies. Without removing gloves or performing hand hygiene, she opened collagen with silver, applied it to the wound, and applied a silicone-bordered dressing. She removed her gloves without performing hand hygiene, exited the room wearing the gown, retrieved tape from the wound cart in the hallway, reentered the room without hand hygiene, and donned clean gloves. She then removed a soiled dressing from the resident’s right foot, left it on the bed, and wrapped the foot with a dry dressing without changing gloves or performing hand hygiene between soiled and clean tasks. After completing wound care, she discarded used dressings and the towel, removed her gown and gloves, and washed her hands. These observations showed failure to follow the facility’s infection control policies for hand hygiene, glove changes, and handling of soiled dressings and clean supplies during wound care under enhanced barrier precautions.
Failure to Involve Residents and Representatives in Routine Care Planning
Penalty
Summary
The deficiency involves the facility’s failure to provide residents and/or their representatives with the opportunity to participate in the care planning process as required. For one cognitively intact resident, the 5‑day MDS showed intact cognition, yet review of the electronic health record revealed that neither the resident nor the resident representative were listed as attendees at multiple care plan meetings. In an interview, this resident reported never being invited to a care plan meeting since admission, was unaware that such meetings were held, and stated he would have liked to attend with his daughter to be actively involved in his care plan. The social worker acknowledged that she had not sent invitations to this resident for care planning meetings and confirmed that quarterly or annual care plan meetings with residents and/or representatives had not been completed. For another resident with dementia with psychotic disturbance, PTSD, abnormal weight loss, failure to thrive, and anemia, MDS assessments documented severe cognitive impairment. Records showed that the resident’s representative received only one written invitation to a care plan conference, which occurred in November and was documented as including the representative. The representative confirmed being notified and invited only once and was unaware that routine care plan conferences should have occurred. The social worker stated she had only been sending invitations and holding care meetings for 72‑hour post‑admission residents or when concerns were expressed, and that she was unaware she should have been inviting all residents and/or representatives on a routine basis based on the MDS calendar. She confirmed that quarterly and annual care plan meetings for all residents and/or representatives had not been completed because she did not know it was her responsibility. The administrator stated she had been made aware that annual and quarterly care plan meetings had not been completed for all residents and that residents and/or representatives were not invited to attend care planning meetings, despite her expectation that plans of care be reviewed quarterly and as needed with them.
Failure to Provide Required Fingernail Care for Dependent Resident
Penalty
Summary
The facility failed to provide adequate fingernail care for a dependent resident who required assistance with activities of daily living, including personal hygiene. The resident was admitted with a contracture of the left hand and reduced mobility and had a care plan indicating an ADL self-care performance deficit, with dependence on staff for personal hygiene. A significant change MDS documented the resident as cognitively intact, without rejection of care, and dependent on others for personal hygiene. Bath skin review sheets for multiple dates documented only toenail condition, with no reference to fingernails. During observations on two consecutive days, the resident’s fingernails on both hands were noted to be jagged or broken, extended more than 1/4 inch past the fingertips, and had a brown substance underneath the free edge of the nails. The left hand fingers were curled inward due to contracture, though no wounds were observed in the palm when the resident uncurled the fingers using the right hand. In interviews, the resident stated a preference for short fingernails, especially on the contracted left hand, explaining that long nails often stabbed into the palm and caused discomfort. The resident reported that NAs sometimes cleaned under her nails but no one had offered to cut them, and later confirmed that although she received a bath, her fingernails were not cleaned. The NA assigned on one of the observation days acknowledged typically checking nails during baths but admitted she did not provide or offer nail care during the resident’s bed bath that morning and did not provide a reason. Nurse #1 stated that it was the assigned nurse’s responsibility to ensure nail care was provided and that nurses were supposed to complete a nail review during weekly skin assessments, but was unsure when the resident was due for such an assessment. Review of the weekly skin assessments showed no documentation regarding the resident’s fingernails on the last recorded assessment, and the DON stated she expected NAs to provide nail care on bath days and had designated an NA to complete weekly nail inspections, but was unsure how this resident’s nail care had been missed.
Late Administration of Anti-Seizure Medications by Agency Nurse
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors when scheduled anti-seizure medications were not administered as ordered. Resident #12, admitted with intractable epilepsy without status epilepticus and with moderately impaired cognition, had active physician orders for Lacosamide 150 mg twice daily via G-tube, Levetiracetam 1000 mg every morning and at bedtime via G-tube, and Phenytoin Sodium Extended 100 mg twice daily via G-tube. The resident’s care plan included an intervention to give anti-seizure medications as ordered by the physician. The March 2026 MAR showed that Phenytoin Sodium Extended 200 mg was scheduled for 8:00 AM, Lacosamide 150 mg for 9:00 AM and 5:00 PM, and Levetiracetam 1000 mg for 9:00 AM and 9:00 PM. On 3/16/26, Nurse #2, an agency nurse who worked intermittently at the facility, did not administer the resident’s scheduled 8:00 AM and 9:00 AM anti-seizure medications until 12:07 PM, resulting in the medications being given 3 to 4 hours late and outside the facility’s acceptable one-hour before/after administration window. In an interview, Nurse #2 stated he fell behind on morning medication administration and did not request assistance to ensure medications were given on time. The DON stated that seizure medications were required to be administered on time, that agency staff had been instructed to request help if they fell behind, and that she was unaware the medications had been given outside the acceptable timeframe. The Medical Director confirmed the late administration of the anti-seizure medications and noted that, although the resident did not appear to have suffered ill effects and vital signs remained within normal limits with no documented seizure activity, the delay could have increased the resident’s risk for seizure activity.
Failure to Accurately Post and Maintain Daily Nurse Staffing Information
Penalty
Summary
The deficiency involves the facility’s failure to accurately post daily nurse staffing information and to ensure that the posted information matched the actual staffing schedule. Record review of 30 days of postings compared to the staffing schedules showed discrepancies on 7 days, including incorrect counts of NAs on various shifts and an incorrect count and classification of an RN and LPNs on one day. The Scheduler confirmed that she did not update the posted staffing sheet when staff called out, were no-shows, or when replacement staff came in, and she acknowledged miscounting an RN as an LPN on one shift. The Administrator stated that the daily posted nurse staffing sheet and the nursing schedule should match the number of staff who actually worked each shift. The facility also failed to ensure that the daily staffing sheet was posted on at least one observed day. During the initial tour and a later observation on the same day, the staffing posting in the reception area was dated several days earlier, indicating that the current day’s staffing information was not displayed. The Scheduler stated that she or the DON were responsible for posting the daily staffing sheets on weekdays and believed the DON had posted the sheet that morning. The DON reported that she had posted the sheet early that morning and suggested it might have been removed for review and not replaced. The Administrator reported being told by the DON that the sheet had been posted and suggested it was possible someone removed it and failed to return it to the display area.
Improper Food Storage and Dating in Facility
Penalty
Summary
The facility failed to properly date leftover food items stored in the dry goods storage area and the walk-in cooler, as observed during a survey. Specific issues included an open and undated bag of corn flakes, an undated bag of leftover brown sugar stored in an unsealed plastic bag, an undated leftover package of sliced cheese, an undated leftover package of sliced ham, and a stainless-steel container with cooked mixed vegetables that had not been dated. These observations were made during a survey conducted on December 2, 2024. Interviews with staff revealed a lack of adherence to proper food storage protocols. The Dietary Manager, who was new to the position, acknowledged her responsibility for ensuring food items were dated and stored correctly. Another staff member indicated awareness that refrigerated leftovers should be used within three days and dry goods should be sealed, labeled with an open date, and used within seven days. The Dietary Aide confirmed that food items should be sealed, dated, and checked daily for expiration. The Administrator also acknowledged the importance of sanitary and safe food practices and noted the Dietary Manager's newness to the role.
Inaccurate MDS Coding for Falls
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) assessments for three residents in the area of falls. Resident #63, who was admitted with vascular dementia, experienced a fall with a minor injury on 9/20/24, which was not recorded in the annual MDS assessment dated 11/9/24. The MDS Coordinator confirmed the oversight during an interview. Similarly, Resident #64, with a history of stroke and repeated falls, had multiple falls between 7/5/24 and 8/7/24, but the quarterly MDS assessment dated 9/15/24 only recorded one fall with minor injury. The MDS Coordinator acknowledged the error, stating it was an oversight. Resident #3, diagnosed with dementia, had falls on 7/24/24 and 8/5/24, both without injuries. However, these incidents were not reflected in the quarterly MDS assessments dated 7/31/24 and 9/15/24, respectively. The MDS Coordinator confirmed the omissions during an interview, attributing them to oversight. The facility's Administrator expressed that it was his expectation for MDS assessments to be coded accurately in the area of falls.
Expired Medications Found in Medication Cart
Penalty
Summary
The facility failed to discard expired medications in one of the two medication carts reviewed for storage and labeling. During an observation of the Masters Hall medication cart, it was found that there were three opened bottles of Latanoprost eye drops, all of which were past the manufacturer's recommended discard date of six weeks after opening. Nurse #1 confirmed the medications were expired and removed them from the cart. She admitted to not checking the medication cart for expired medications on the day of the observation. The Director of Nursing stated that all nurses were responsible for checking the dates on multi-use medications before administration to ensure they were not expired. However, there was no set schedule for unit managers to check the medication carts for expired medications. The facility Pharmacist, who visits every other month, also checks the medication carts for expired medications but did not recall which carts were reviewed during the last visit in October. The Pharmacist confirmed the manufacturer's recommendation for discarding Latanoprost eye drops six weeks after opening.
Failure to Provide Annual Dementia Training for Nursing Assistants
Penalty
Summary
The facility failed to ensure that Nursing Assistants (NAs) received their required annual Dementia training. This deficiency was identified for four NAs, who had not received Dementia training since June 2023. The NAs in question had been employed at the facility for varying lengths of time, with hire dates ranging from December 1999 to December 2022. During interviews, both the Director of Nursing (DON) and the Administrator acknowledged the oversight, attributing it to the absence of the Staff Development Coordinator (SDC) due to medical leave since October 2024. The DON confirmed that the Dementia training should be completed yearly, and the Administrator stated it was his expectation that the NAs receive this training annually.
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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