The Laurels Of Pender
Inspection history, citations, penalties and survey trends for this long-term care facility in Burgaw, North Carolina.
- Location
- 311 S Campbell Street, Burgaw, North Carolina 28425
- CMS Provider Number
- 345298
- Inspections on file
- 20
- Latest survey
- January 15, 2026
- Citations (last 12 mo.)
- 12
Citation history
Health deficiencies cited at The Laurels Of Pender during CMS and state inspections, most recent first.
Surveyors found multiple opened insulin pens and an insulin vial on several medication carts without documented opened dates, despite manufacturer instructions requiring discard after a set number of days once opened. A medication aide on one hall reported that staff were responsible for checking carts for expired medications but stated she did not check insulin dates because she could not administer insulin, while the unit manager confirmed nurses were expected to date insulin pens when opened and identified from pharmacy labels when the pens were received. On another cart, a nurse acknowledged that all nurses were responsible for ensuring insulin products were dated when opened and that the undated Tresiba pen, Lispro vial, and Insulin Glargine pen should have been labeled so staff would know their use-by timeframe. On a skilled care cart, another medication aide similarly stated that all staff should check for expired medications but did not check insulin dates, and the overseeing unit manager admitted she should have verified that all opened insulin pens were dated. The DON stated her expectation that nurses date all insulin pens and vials upon opening so staff can determine if they remain appropriate for use.
Surveyors found that staff failed to properly label, date, and discard opened and expired food items in the kitchen freezers, dry goods storage, and nourishment rooms. Opened bread products in the freezers and dry storage lacked opened and expiration dates, and an opened nectar-consistency nutritional supplement in a nourishment room had no date despite manufacturer instructions for use within a limited time. Disposable food containers labeled with a resident’s name were either missing dates or not discarded within the facility’s stated three-day limit for outside food. The Dietary Manager and Administrator acknowledged expectations that nursing staff label outside food and dietary staff monitor and discard expired items, but these practices were not consistently followed.
A resident admitted with bipolar disorder, dementia, and anxiety was started on multiple psychotropic medications, including an antipsychotic, an anticonvulsant/mood stabilizer, and an antidepressant, which were administered as ordered. The admission MDS showed the resident was cognitively intact and receiving these medications, but review of the electronic record found no completed psychotropic consent form and no documentation that risks versus benefits of the medications had been reviewed with the resident or a representative. The unit manager, NP, and DON all confirmed that the psychotropic consent form should have been completed by the admitting nurse at admission, with a discussion of risks versus benefits prior to medication administration, but this did not occur or was not documented.
A resident with ESRD and a right upper arm A/V fistula, documented by the hospital and facility staff as positive for bruit and thrill but not yet mature, was admitted and later readmitted with a right chest permacath for dialysis. Although the care plan referenced protecting and monitoring the fistula, physician orders and the MAR addressed only the permacath, with no orders to assess the A/V fistula for bruit, thrill, or signs of infection, and no formal restrictions on blood pressures or lab draws in that arm. Multiple nurses, the unit manager, wound nurse, NP, and DON acknowledged the presence of the fistula and indicated that “batch orders” for fistula care should have been initiated on admission, but these orders were never entered, resulting in the fistula not being formally assessed or managed per provider orders.
A resident with orthostatic hypotension was prescribed midodrine with specific blood pressure hold parameters, yet nursing staff and medication aides repeatedly documented administering the drug when systolic blood pressure readings exceeded the ordered threshold. During two consecutive monthly medication regimen reviews, the Consultant Pharmacist reviewed the MARs but documented no new irregularities and did not address these administrations outside the ordered parameters. In interviews, the pharmacist acknowledged that his review process should have identified medications given outside ordered parameters and admitted missing these irregularities, while the DON confirmed that identifying such issues was an expected part of the monthly review.
A resident with hypotension had an order for midodrine 2.5 mg BID with instructions to hold the dose if SBP exceeded 120 mm/Hg or DBP exceeded 80 mm/Hg, but the MAR repeatedly showed the drug as administered despite recorded SBP values above the ordered parameter. Multiple nurses and a medication aide later stated they had either held the medication or not given it, yet documented it as administered on the electronic MAR. The DON reported that medications were expected to be documented accurately and that held medications should be recorded as held with the reason, and confirmed that documentation for this resident’s midodrine was inaccurate.
Surveyors found that staff failed to follow the facility’s Enhanced Barrier Precautions (EBP) policy when two nurse aides provided incontinence care to a resident with a tracheostomy, gastrostomy tube, and Stage IV sacral pressure ulcer while wearing gloves but not gowns, despite EBP signage and PPE supplies at the room and prior infection control training. The Infection Control Preventionist and DON confirmed that gowns should have been used for this high-contact care under EBP. In addition, the facility did not follow its Tuberculosis Control Plan for a newly admitted resident: although Step 1 of the two-step tuberculin skin test (TST) was completed with a negative result, Step 2 was not administered within the required 1–3 week window and was delayed for several months after an initial documented refusal, without timely re-offer, contrary to facility policy and acknowledged guidelines.
A resident admitted after surgical repair of a left femur fracture had hospital orders for Aquacel dressing and a subsequent physician order for weekly cleansing and silicone foam with silver dressing to the left thigh incision, with a care plan directing wound treatments as ordered and monitoring for infection. Despite these orders, no wound care was documented for nearly two weeks, and the Treatment Administration Record showed one missed treatment without explanation in the progress notes. An RN reported the resident refused care once and never received wound care from her, while the Wound Nurse acknowledged not completing or documenting wound care attempts after reported refusals. A nurse aide stated the resident would often accept care if re-approached. When wound care was finally performed, the original hospital dressing remained in place, and only then was the incision assessed and redressed, contrary to the ordered schedule.
A nursing assistant misappropriated funds from a resident by using the resident's bank account information to create a Cash App account and transferring money to herself and family members. The resident, who had multiple chronic health conditions and was assessed as cognitively intact, denied ever giving permission for these transactions. The misappropriation was discovered by a family member and confirmed through facility investigation and law enforcement, with the nursing assistant ultimately admitting to accepting money in violation of facility policy.
Failure to Date Opened Insulin Pens and Vials on Medication Carts
Penalty
Summary
The deficiency involves the facility’s failure to ensure that multi-dose insulin pens and an insulin vial were dated when opened, as required to comply with manufacturer instructions for safe use. During observation of the 400-hall medication cart with a medication aide, surveyors found opened Humalog and Lantus prefilled insulin pens without an opened date, despite manufacturer directions to discard them 28 days after opening. The medication aide stated that nurses and medication aides were responsible for checking medication carts for expired medications but explained that, as a medication aide, she could not administer insulin and did not check dates on insulin products. The unit manager for that hall stated that nurses should be checking the carts to ensure there were no expired medications and that all insulin pens were dated once opened, and she identified from the pharmacy labels that the Lantus and Humalog pens had been received on 01/12/26 and had been used without being dated when opened. On the 100-hall long-term care medication cart, observed with a nurse, surveyors found an opened Tresiba prefilled insulin pen, an opened Lispro insulin vial, and an opened Insulin Glargine prefilled insulin pen, all without opened dates, even though manufacturer instructions required discarding Tresiba 56 days after opening and the Lispro vial and Insulin Glargine pen 28 days after opening. The nurse stated that all nurses were responsible for checking their medication carts for expired medications and ensuring insulin pens and vials were dated when opened, and acknowledged that these insulin products should have had an opened date so staff would know when they should be used by. On the 100-hall skilled care medication cart, observed with another medication aide, an opened Lantus prefilled insulin pen was found without an opened date, despite manufacturer instructions to discard after 28 days once opened. This medication aide stated that all nurses and medication aides were responsible for checking medication carts for expired medications but, as a medication aide who could not administer insulin, she did not check opened dates on insulin pens. The overseeing unit manager stated she should have checked the cart at the start of the shift to ensure all insulin pens were dated once opened. The DON reported that her expectation was that once an insulin pen or vial was opened, nurses should place an opened date on it so they could determine if the medication was still good for use according to manufacturer instructions.
Failure to Label, Date, and Discard Opened and Expired Food Items
Penalty
Summary
Surveyors identified a deficiency related to food storage and labeling practices in the facility’s kitchen, freezers, dry goods storage, and nourishment rooms. During an initial kitchen tour with the Dietary Manager, surveyors observed multiple opened food items in the front kitchen freezer and an outside freestanding freezer, including bread sticks, biscuits, and garlic bread, that lacked any opened dates or expiration dates. In the dry goods storage room, an opened package of hamburger buns and an opened loaf of bread that were no longer in their original packaging were also found without opened dates or expiration dates. The Dietary Manager acknowledged that all opened foods in the freezer and dry goods storage should be labeled with the date opened and the expiration date. Further observations in the nourishment rooms revealed additional labeling and dating failures. In the 400-hall nourishment room, surveyors found an opened container of nectar-consistency nutritional supplement with no opened date or expiration date, despite the manufacturer’s label stating it should be consumed within four days of opening. A disposable food container labeled with a resident’s name but without a date received or expiration date was also present. In the 100-hall nourishment room, a disposable food container with a resident’s name was dated but not discarded after the facility’s stated three-day limit for outside food. The Dietary Manager stated there should not be any expired food in the nourishment rooms, that nursing staff were responsible for labeling outside food with the resident name and date received, and that dietary staff were responsible for monitoring expiration dates and discarding expired food and supplements. The Administrator stated he expected staff to check for expired food and to label and date food stored in the kitchen and nourishment rooms.
Failure to Obtain and Document Informed Consent for Psychotropic Medications
Penalty
Summary
The deficiency involves the facility’s failure to obtain and document informed consent for psychotropic medications prior to administration for one resident. Resident #98 was admitted with diagnoses including bipolar disorder, dementia, and anxiety, and had physician orders dated 01/07/26 for multiple psychotropic medications: Amitriptyline 25 mg, two tablets in the evening for bipolar disorder; Depakote Sodium ER 500 mg, three tablets in the evening for dementia; and Seroquel 300 mg, one tablet in the evening for dementia. The Medication Administration Record from 01/07/26 through 01/15/26 showed that these medications were administered as ordered during this period. The admission MDS assessment documented that the resident was cognitively intact and received antipsychotic, anticonvulsant, and antidepressant medications during the assessment period. Record review revealed no documentation that Resident #98 or a resident representative had consented to, or had been informed in advance of, the risks versus benefits of receiving Seroquel and Amitriptyline. Unit Manager #2 explained that the admission packet includes a checklist, with item #6 being the psychotropic medication consent form that should be reviewed and signed and is located in the electronic record; upon review of the electronic record, she confirmed there was no documentation of this consent or of a risks-versus-benefits discussion. The Nurse Practitioner stated that the psychotropic consent form should have been completed upon admission and that it was important for the nurse to inform the resident of the risks versus benefits of each psychotropic medication prior to administration. The DON similarly reported that the psychotropic consent form should have been completed by the admitting nurse at admission, with risks versus benefits discussed for each ordered psychotropic medication before the medications were given.
Failure to Obtain and Implement Orders for Assessment of Maturing A/V Fistula in Dialysis Resident
Penalty
Summary
The deficiency involves the facility’s failure to obtain and implement provider orders to assess and manage a maturing right upper extremity arteriovenous (A/V) fistula for a resident with end stage renal disease who was dependent on dialysis. Hospital records dated 12/08/25 documented that the resident had an A/V fistula placed in October 2025 in anticipation of dialysis, which was positive for bruit and thrill but not yet mature, and that a permacath was placed during that hospitalization. On admission and readmission to the facility in December 2025 and January 2026, the resident’s diagnoses included end stage renal disease with dependence on renal dialysis, and the Minimum Data Set reflected that the resident was receiving dialysis services. The care plan dated 12/17/25 identified risk for complications related to dialysis and included interventions such as not drawing blood or taking blood pressure in the arm with the fistula, observing for signs of infection, palpating for thrill, and listening for bruit, with instructions to report abnormalities to the physician. Despite these care plan interventions, the physician orders written on 12/18/25 and again on 01/11/26 addressed only the permacath, specifying dialysis days and monitoring the catheter site for bleeding, infection, and intact caps, with no orders to assess or protect the right arm A/V fistula. Nursing documentation, including skilled care notes and skin assessments, repeatedly acknowledged the presence of the right upper arm A/V fistula and described it as positive for bruit and thrill or as a dialysis access, while also noting the right chest permacath. The Medication Administration Records for December 2025 and January 2026 showed that staff were documenting assessments of the permacath site but contained no orders or documentation for assessment of the A/V fistula site. Interviews with staff confirmed that no orders were initiated for the A/V fistula on either admission. One nurse stated she assessed the A/V fistula and found a positive bruit and thrill but did not enter any orders, explaining that unit managers usually entered “batch orders” for A/V fistulas, which would include assessing bruit and thrill, monitoring for infection, and restricting blood pressures and lab draws in the affected arm. The unit manager, wound treatment nurse, nurse practitioner, and DON each acknowledged awareness of the A/V fistula’s presence, with some staff mistakenly believing it was an old, non-functioning access and others stating that admitting nurses should have initiated batch orders for the maturing fistula. The DON and unit manager confirmed that orders to assess the A/V fistula site were not entered on either admission, despite expectations that such orders should have been in place.
Consultant Pharmacist Failed to Identify Midodrine Dosing Outside Ordered Parameters
Penalty
Summary
A deficiency occurred when the Consultant Pharmacist failed to identify and report a medication irregularity during two consecutive monthly medication regimen reviews for one resident receiving midodrine for orthostatic hypotension. The resident had an order for midodrine 2.5 mg twice daily with instructions to hold the medication if the systolic blood pressure (SBP) exceeded 120 mm/Hg or the diastolic blood pressure exceeded 80 mm/Hg. Review of the November medication administration record (MAR) showed multiple instances where midodrine was documented as administered despite SBP readings above the ordered parameter, including blood pressures of 124/53, 124/68, 129/54, and 129/56 mm/Hg. The Consultant Pharmacist’s November medication regimen review, dated 11/18/25, documented that there were no new irregularities and did not address these administrations outside the ordered parameters. In December, the MAR again showed repeated administrations of midodrine when the resident’s SBP exceeded the ordered hold parameter, with documented blood pressures such as 122/67, 121/66, 132/60, 121/60, 121/67, 122/61, 124/62, 128/61, 131/72, 139/74, 124/69, and 134/68 mm/Hg at the time the medication was signed as given by various nurses and medication aides. The Consultant Pharmacist’s December medication regimen review, dated 12/18/25, again stated there were no new irregularities and did not address the ongoing administration of midodrine outside the specified parameters. In a subsequent interview, the Consultant Pharmacist acknowledged that his monthly review process included checking current and prior MARs for medications given outside ordered parameters, stated that such doses should have been documented as held when outside parameters, and admitted that he should have addressed these irregularities but missed them due to human error. The DON confirmed that the Consultant Pharmacist was expected to identify such issues during the monthly reviews.
Inaccurate MAR Documentation for Parameter-Dependent Midodrine Administration
Penalty
Summary
The deficiency involves the facility’s failure to maintain accurate documentation on the Medication Administration Record (MAR) for a resident receiving midodrine for hypotension. The physician’s order dated 11/6/25 directed that midodrine 2.5 mg be given twice daily and held if the systolic blood pressure (SBP) was over 120 mm/Hg or the diastolic blood pressure was over 80 mm/Hg. The MAR for November, December, and January reflected this order, yet multiple entries showed blood pressure readings above the ordered SBP parameter with the medication still documented as administered. Specific examples included blood pressures of 124/53, 129/54, 132/60, 122/61, 124/62, 134/68, 126/66, and 127/70 mm/Hg, all recorded with midodrine signed out as given. During interviews, the nursing staff and medication aide involved acknowledged that their documentation on the electronic MAR was incorrect. One nurse stated that on 11/15/25 she documented that she administered midodrine when she had not. Another nurse reported that when the resident’s blood pressure was outside the ordered parameters, he held the medication but erroneously documented it as administered on several dates. The medication aide similarly stated that she documented in error that she administered midodrine on two January administrations. The DON stated that her expectation was that medications be administered and documented accurately, and that when a medication is held it should be documented as held with the reason, and acknowledged that the resident’s midodrine was not documented accurately, emphasizing the importance of accurate documentation for evaluation of the resident’s medical condition.
Failure to Follow Enhanced Barrier Precautions and TB Screening Protocols
Penalty
Summary
Surveyors identified that the facility failed to implement its infection control policy and procedures for Enhanced Barrier Precautions (EBP) during direct care of a resident with complex medical needs. The resident had a tracheostomy, a gastrostomy tube, and a Stage IV sacral pressure ulcer, and an EBP sign was posted on the room door with a PPE supply bag containing gloves and gowns. During an observation, two nurse aides provided incontinence care to this resident while wearing gloves but did not don gowns, despite the EBP requirements for targeted gown and glove use during high-contact resident care activities. Both aides reported they did not know they were required to wear gowns when providing care to this resident and expressed confusion about PPE use and the purpose of EBP, even though they stated they had received infection control training. The Infection Control Preventionist Nurse confirmed that staff had received infection control training on EBP and were required to complete monthly infection control in-services through an online platform. She stated that the two nurse aides should have worn gowns along with gloves when providing direct care to the resident on EBP. The DON also stated that staff received infection control training and were expected to follow infection control guidelines and wear PPE when providing direct care to residents on EBP. These statements confirmed that the observed care did not comply with the facility’s written EBP policy and expectations for PPE use. Surveyors also found that the facility failed to follow its Tuberculosis (TB) Control Plan for a newly admitted resident. The policy required all first-time residents to receive a two-step tuberculin skin test (TST) on admission, with Step 2 administered 1–3 weeks after Step 1 if the initial reaction was less than 10 mm. The resident received Step 1 with a negative result of 0.1 mm, but Step 2 was not administered within the required 1–3 week timeframe and instead was given several months later. The Infection Control Preventionist Nurse reported that the Medication Administration Record showed the resident refused Step 2 on one date, but acknowledged that staff should have re-offered the test within the required timeframe and that this did not occur. The resident, who was cognitively intact, did not recall refusing the test and stated she would have agreed to complete Step 2 if it had been offered again. The Nurse Practitioner and DON both indicated that the two-step TST guidelines called for Step 2 to be given within 1–3 weeks after Step 1, confirming that the facility did not follow its TB screening policy for this resident.
Failure to Follow Physician Orders for Post-Surgical Wound Care
Penalty
Summary
The deficiency involves the facility’s failure to follow physician orders and provide timely wound care to a resident with a left femur fracture surgically repaired prior to admission. The hospital discharge summary ordered Aquacel dressing to remain in place on the left surgical wound for seven days and then be replaced with new Aquacel. Upon admission, the Wound Nurse entered a physician’s order to cleanse the left lateral thigh wound with wound cleanser, apply a protective barrier to the peri-wound, and cover with a silicone foam with silver dressing every seven days and as needed. The resident’s care plan identified risk for complications from the left thigh surgical wound, with goals for healing without infection and interventions to observe for signs of infection, report abnormalities to the physician, and provide wound treatments as ordered. The MDS admission assessment documented that the resident had moderately impaired cognition, occasional rejection of care, and a surgical wound, but no wound care. From admission through mid-month, there was no documented evidence that wound care was provided to the resident’s left femur surgical wound. The TAR showed that on one date Nurse #6 coded wound care as not performed and directed to see progress notes, but the progress notes contained no explanation for the missed treatment and no documentation of any wound care from admission through that date. In interviews, Nurse #6 stated the resident refused wound care on that date and that she reported the refusal to the Wound Nurse, and also stated she never provided wound care to the resident at any time. The Wound Nurse confirmed that wound care had not been completed because of a reported refusal and that she did not document her own attempt when the resident refused on another day. A nurse aide reported that the resident sometimes refused care but would usually accept it with redirection or re-approach. When wound care was finally observed nearly two weeks after admission, the original hospital dressing dated several days before admission was still in place, and the Wound Nurse then removed it and applied a new silicone foam dressing. The DON and Medical Director both stated that wound care should have been provided according to the physician’s order and sooner than 13 days after admission.
Misappropriation of Resident Funds by Nursing Assistant
Penalty
Summary
A nursing assistant (NA) used a resident's bank account information without permission to create a Cash App account in the resident's name and transferred funds to herself and her family members over several months. The resident, who had multiple chronic medical conditions including chronic respiratory failure, diabetes, heart failure, and hemiplegia, was assessed as cognitively intact on the Minimum Data Set. The misappropriation was discovered when a family member noticed unusual transactions on the resident's bank statement and brought it to the attention of the facility's Business Office Manager (BOM). The transactions, which totaled over $8,000, were linked to the NA through matching names on the Cash App transactions and the NA's personnel file and social media accounts. Upon being confronted, the NA initially denied involvement but later admitted to accepting money from the resident, claiming it was given as gifts or with permission. However, the resident consistently denied ever giving the NA permission to use her bank information or debit card, and stated she was unaware of Cash App until the incident was explained to her. Interviews with law enforcement, the BOM, the former Director of Nursing (DON), and the resident's family corroborated that the NA had accessed the resident's financial information without authorization and used it for personal expenses, including bills and purchases unrelated to the resident's care. The facility's investigation revealed that the NA had violated the facility's policy prohibiting staff from accepting gratuities or gifts from residents. The incident was reported to local law enforcement, Adult Protective Services, and the state regulatory agency. The NA was terminated following the investigation. The resident experienced emotional distress as a result of the theft, expressing anger and hurt over the loss of her money. The case was also investigated by the North Carolina Nursing Assistant Registry, which confirmed the misappropriation of funds.
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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