The Lodge At Rocky Mount Health And Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Rocky Mount, North Carolina.
- Location
- 3322 Village Road, Rocky Mount, North Carolina 27804
- CMS Provider Number
- 345137
- Inspections on file
- 25
- Latest survey
- April 10, 2026
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at The Lodge At Rocky Mount Health And Rehabilitation during CMS and state inspections, most recent first.
Surveyors found multiple opened medications without dates and expired drugs remaining on several medication carts and in a medication room. On one cart, a nurse had undated ophthalmic ointment, inhaler, creams, eye drops, and artificial tears, all with manufacturer discard timeframes after opening. Another cart overseen by a CMA contained an opened multivitamin with iron past its expiration date, despite the CMA reporting she checks for expired meds daily. A third cart had expired Melatonin tablets and glucose gel, along with undated Fluticasone nasal sprays and Nystatin cream. In a medication room managed by a unit manager, surveyors found expired multivitamins and an undated, accessed Tuberculin PPD vial in the refrigerator. The UM, DON, and Administrator all stated that nurses, CMAs, and nursing administration were responsible for dating opened meds and routinely checking carts and rooms for expired medications.
The facility failed to accurately post daily nurse staffing information when reception staff, using schedules prepared from a master schedule, completed the public staffing report without understanding that some RNs, LPNs, and NAs were splitting shifts or working 12‑hour shifts. Receptionists counted each name on the schedule as a full staff member for the entire shift, did not receive updates on call‑outs or schedule changes, and did not revise the posted report once it was placed in the lobby. The Scheduler did not communicate staffing changes to reception, and the Administrator did not review the report for accuracy, resulting in repeated discrepancies between posted staffing levels and actual scheduled staffing across all three shifts on most days reviewed.
Surveyors found that MDS assessments were inaccurately coded for two residents: one resident receiving clopidogrel was incorrectly coded as taking an anticoagulant instead of an antiplatelet, and another resident with severe dementia who wore a wander/elopement alarm bracelet was not coded for alarm use on the quarterly MDS. The MDS nurse reported she misinterpreted an order referencing anticoagulant monitoring in the first case and did not code the alarm in the second case because there was no physician order, despite knowing the alarm was in place and it being documented in the care plan and elopement risk assessment.
A resident with significant medical needs slid out of her wheelchair during van transport after an abrupt stop, resulting in her foot becoming wedged and a subsequent ankle fracture. The transport driver, lacking specific emergency training, moved the resident without a clinical assessment and continued to the hospital, where the injury was later identified and treated. Interviews confirmed the resident was not assessed by a licensed professional prior to being moved.
A resident with right-sided hemiparesis and dependent on staff for wheelchair mobility was not properly secured in a facility van during transport, as the lap/shoulder belt was placed over the wheelchair armrest instead of directly against the body. During an abrupt stop, the resident slid out of the wheelchair, resulting in a trimalleolar ankle fracture that required a splint and opioid pain management.
The facility failed to maintain kitchen equipment in a sanitary condition, with seven out of nine baking sheets found with dark dried grease buildup. Observations revealed these unsanitary baking sheets were stacked and ready for use. The Dietary Manager and Administrator acknowledged the need for proper cleaning and adherence to the cleaning schedule.
The facility failed to implement its infection prevention and control program for droplet precautions, as observed with three staff members not adhering to protocols for residents with influenza. A Social Worker and a Nurse Aide exited rooms without removing their surgical masks, and the Maintenance Director entered a room without wearing a mask. Despite education on the procedures, these lapses occurred, highlighting a deficiency in following established infection control measures.
A resident with generalized epilepsy did not receive phenytoin for 19 days due to a mismanaged medication order. The Unit Manager mistakenly discontinued the order without proper verification, and the error went unnoticed until the resident was hospitalized for an unrelated issue. The facility lacked a robust process to ensure medication orders were correctly implemented.
A facility failed to develop a care plan for a resident with hearing impairment. The resident, with moderate cognitive impairment and hearing difficulty, was found without hearing aids, which were charging nearby. Staff interviews revealed confusion over responsibility for implementing the care plan, with the Social Worker admitting to missing it. The Administrator confirmed the oversight but could not recall if it was reviewed in meetings.
A resident with a neurogenic bladder experienced discomfort due to unsecured indwelling catheter tubing. Despite a physician's order to check catheter securement every shift, staff interviews and observations revealed inconsistent adherence to this directive, with the tubing often left unsecured and the leg strap not consistently used.
Failure to Date Opened Medications and Remove Expired Drugs From Carts and Medication Room
Penalty
Summary
The deficiency involves failure to ensure medications were properly dated when opened and that expired medications were removed from use on multiple medication carts and in a medication room. During an observation of the North Hall 3 medication cart with a nurse, surveyors found several opened and used medications without dates, including Erythromycin ophthalmic ointment, a Trilogy Elipta inhaler, Nystatin cream, Clotrimazole Betamethasone Dipropionate lotion, Rhopressa eye drops, and artificial tears, all of which had manufacturer instructions specifying discard timeframes after opening. The nurse stated that all medications in the cart were supposed to be dated when opened and that it was the responsibility of the nurse assigned to the cart to check it. On the North Hall 1 medication cart, observed with a CMA, surveyors found an opened and used bottle of multivitamin with iron with remaining pills and an expiration date that had already passed; the CMA stated she checks the cart daily for expired medications and had missed that bottle. On the South Hall medication cart, observed with another CMA, surveyors identified an opened bottle of Melatonin tablets and an unopened box of microdot glucose gel, both past their expiration dates, as well as four undated, opened bottles of Fluticasone Propionate nasal spray and one undated, opened Nystatin cream tube, all with manufacturer discard instructions after opening. In the South Hall medication room, observed with the South Unit Manager, surveyors found two unopened bottles of multivitamins past their expiration date and an undated, accessed bottle of Tuberculin PPD solution in the refrigerator. The South Unit Manager stated she was responsible for the medication room and that medication rooms were to be checked weekly by unit managers, and acknowledged that the PPD should have been dated when opened and that the refrigerator should be included in checks. The DON and Administrator both stated that nursing staff and nursing administration were responsible for checking medication carts and rooms and for dating and discarding medications, but were unsure how the identified issues were missed.
Inaccurate Posting of Daily Nurse Staffing Information
Penalty
Summary
The deficiency involves the facility’s failure to post accurate daily licensed and unlicensed nurse staffing information for the majority of days reviewed. Surveyors compared the posted “Report of Nursing Staff Directly Responsible” with the daily nursing schedules and Salaried Employee Sheets over a one‑month period and found discrepancies on 28 of 31 days. For multiple dates and shifts, the numbers of RNs, LPNs, and NAs listed on the posted report did not match the actual staffing reflected on the internal schedules and payroll-related records. Examples included days where the posted report showed more NAs or LPNs than were scheduled, days where RNs were listed on the report but were either not scheduled or marked as off on the Salaried Employee Sheet, and days where the posted counts of staff were higher or lower than the daily schedule for all three shifts. The inaccuracy was linked to how the Report of Nursing Staff Directly Responsible was prepared and the lack of understanding of split shifts and 12‑hour shifts by the staff completing the form. The Staff Development Coordinator (SDC) created the master nursing schedule, and the Scheduler generated the daily staffing schedule from it. The Scheduler then emailed the daily schedule to reception staff, who were responsible for completing and posting the report in the lobby. Receptionists reported that they had been trained by the previous Business Office Manager and other reception staff to count each name on the schedule as one staff member for the shift totals. They did not understand that when two names were listed for the same assignment, this represented two staff splitting one shift, not two full staff for the entire shift. As a result, they routinely overcounted staff when shifts were split. Reception staff also reported that they completed and posted the report in the morning and did not update it throughout the day. They stated they did not receive information about call‑outs or schedule changes and therefore did not adjust the posted staffing numbers once the form was initially completed. The Scheduler confirmed that she did not complete the posted report and did not take staff call‑outs or notify reception of changes to the daily staffing schedule. The previous Business Office Manager acknowledged that she had trained reception staff to count each person listed on the schedule as one staff member and was not aware that two people listed for the same assignment could indicate a split shift. The Administrator stated that she had not been reviewing the Report of Nursing Staff Directly Responsible for accuracy prior to its posting, which contributed to the ongoing posting of inaccurate staffing information over the review period. No specific residents, medical histories, or clinical conditions were described in relation to this deficiency. The focus of the findings was on the facility’s processes, documentation, and staff understanding related to the preparation and posting of daily nurse staffing information, and the repeated discrepancies between what was posted for public view and what was actually scheduled and recorded internally.
Inaccurate MDS Coding for Anticoagulant/Antiplatelet Use and Wander Alarm
Penalty
Summary
The facility failed to ensure accurate coding of the MDS assessments for two residents in the areas of anticoagulant/antiplatelet medication use and use of a wander/elopement alarm. For one resident admitted with hypertension, the clinical record showed a physician order and MAR documentation for daily clopidogrel, an antiplatelet medication, with no anticoagulant medication ordered or administered during the assessment period. However, the admission MDS assessment was coded to indicate the resident was receiving an anticoagulant and did not reflect antiplatelet use. In interview, the MDS nurse acknowledged that she had incorrectly coded anticoagulant use after seeing an order to monitor for signs and symptoms related to anticoagulant therapy and confirmed the assessment should have been coded for antiplatelet medication instead. For another resident with severe unspecified dementia and a history of attempting to exit the facility without alerting staff, the care plan documented a wander guard on the right ankle initiated earlier in the stay, and an elopement risk assessment completed upon readmission documented that a wander/elopement alarm bracelet was placed. A quarterly MDS assessment for this resident showed severe cognitive impairment but did not code the use of a wander/elopement alarm. Observation later confirmed the resident was wearing a wander/elopement alarm bracelet on the right ankle, and the active physician orders did not include an order for the device. The MDS nurse stated she was aware the resident had a wander/elopement alarm bracelet but believed she had not coded it because there was no physician order, and the Administrator stated the MDS nurse should have used physical observation or nursing staff input to determine if the alarm was in place to ensure accurate coding.
Failure to Assess Resident for Injury Prior to Movement After Fall During Transport
Penalty
Summary
A deficiency occurred when a resident, who had a history of stroke with right-sided hemiparesis, end-stage renal disease requiring dialysis, anxiety, and depression, was being transported to a medical appointment. During the trip, the transportation driver made an abrupt stop to avoid a collision, causing the resident to slide out of her wheelchair and wedge her left foot under the driver's seat. The driver, who was a Nursing Assistant and Medication Assistant but had not received specific training for such emergencies, pulled the resident's foot out, repositioned her in the wheelchair, and continued driving to the hospital without having the resident assessed for injury by a qualified professional prior to moving her. Upon arrival at the hospital, the resident had again slid out of the wheelchair, with her back against the legs of the wheelchair and the rest of her body on the floor of the van. The resident was observed to have a visibly swollen ankle and was in significant pain. Hospital staff assisted in moving the resident and directed that she be taken to the Emergency Department, where she was diagnosed with a nondisplaced trimalleolar fracture of the left ankle. The resident required pain management and immobilization of the ankle. Interviews with the transportation driver, the resident, the facility administrator, and the physician confirmed that the resident was not assessed by a licensed medical professional prior to being moved after the fall. The physician specifically stated that residents should always be assessed after a fall by a licensed professional before being moved, as moving without assessment could result in further injury. The transportation driver admitted to not contacting the facility immediately and to lacking training on emergency procedures during transport.
Failure to Properly Secure Resident in Transport Van Results in Injury
Penalty
Summary
A deficiency occurred when a resident was not safely secured in a facility transportation van according to the manufacturer's instructions during a trip to a medical appointment. The resident, who had a history of stroke with right-sided hemiparesis, end-stage renal disease requiring dialysis, and was dependent on staff for transfers and wheelchair mobility, was being transported by a facility driver. During the trip, the driver made an abrupt stop to avoid a collision, causing the resident to slide out of her wheelchair, with her left foot becoming wedged under the driver's seat. The driver stopped the van, repositioned the resident, and continued to the hospital. Upon arrival, the resident had again slid out of the wheelchair, with her back against the wheelchair legs and the rest of her body on the van floor. The manufacturer's instructions for the van's securement system specified that the lap and shoulder belts should be positioned directly against the passenger's body, not obstructed by wheelchair components such as armrests, and should be worn low across the pelvis. However, during a reenactment, it was demonstrated that the lap/shoulder belt had been placed over the wheelchair's armrest, preventing it from being firmly pressed against the resident's lap. This improper securement allowed the resident to slide out of the wheelchair during sudden vehicle movement. Staff interviews and observations confirmed that the resident was not secured per the manufacturer's guidelines, and the armrest of the wheelchair interfered with proper belt placement. As a result of the improper securement, the resident suffered a nondisplaced trimalleolar fracture of the left ankle, which required a splint and opioid medication for pain management. The incident was documented in medical records, and interviews with staff, the resident, and the physician confirmed the sequence of events and the resulting injury. The deficiency affected one of three residents reviewed for accidents.
Unsanitary Kitchen Equipment
Penalty
Summary
The facility failed to maintain kitchen equipment in a clean and sanitary condition, specifically concerning seven out of nine baking sheets. During an observation on February 5th, the dish drying rack in the kitchen was found to have seven stacked baking sheets with dark dried grease built up under the rim. A subsequent observation on February 6th revealed that the same baking sheets were stacked and ready for use on the rolling food preparation rack, still in the same unsanitary condition. In an interview, the Dietary Manager acknowledged that staff should have cleaned the baking sheets to remove the grease buildup. The Administrator also stated that the dietary department should adhere to their cleaning schedule and ensure a deep clean of the baking sheets.
Failure to Adhere to Droplet Precautions for Influenza
Penalty
Summary
The facility failed to implement its infection prevention and control program policies and procedures, specifically regarding droplet precautions for residents with influenza. Three staff members, including a Social Worker, Maintenance Director, and Nurse Aide, did not adhere to the established protocols. The Social Worker was observed exiting a resident's room on droplet precautions without removing her surgical mask, despite having been educated on the necessary infection control measures. She confirmed her awareness of the droplet precautions but was unaware that removing the mask upon exiting was part of the protocol. The Maintenance Director was observed entering and exiting a resident's room on droplet precautions without wearing a surgical mask. He acknowledged the oversight, stating he entered the room briefly to move a bedside table and confirmed his understanding that a mask should have been worn. The Infection Preventionist confirmed that all staff had been educated on the droplet precautions, which included wearing a mask before entering and removing it upon exiting the room. Nurse Aide #1 was also observed exiting a resident's room on droplet precautions without removing her surgical mask. She admitted to forgetting to remove the mask, despite having received education on the protocol earlier that day. The Infection Preventionist reiterated that all staff had been educated on the requirements, and the facility had posted instructions on each resident's room. The facility had also taken measures to minimize the spread of influenza, such as offering vaccines and monitoring residents for symptoms.
Medication Order Mismanagement Leads to Non-Administration of Seizure Medication
Penalty
Summary
The facility failed to clarify a physician order for phenytoin, a medication used to treat epilepsy, for a resident diagnosed with generalized epilepsy. This oversight resulted in the medication not being administered for 19 days. The resident had a physician order for phenytoin sodium extended 100 mg capsule to be given twice a day on specific days of the week. However, due to a misunderstanding, the order was discontinued by the Unit Manager without proper verification or a physician's directive to do so. The resident, who had moderate cognitive impairment and a history of phenytoin toxicity, was admitted with diagnoses including generalized epilepsy and stroke. A laboratory result indicated a sub-therapeutic phenytoin level, prompting the Nurse Practitioner to increase the dosage. However, the Unit Manager mistakenly discontinued the new order, believing it to be a duplicate, and did not verify the change with the Nurse Practitioner. This error went unnoticed until the resident was hospitalized for an unrelated incident. Interviews with facility staff revealed a lack of communication and verification processes. The Unit Manager did not review the end-of-day communication from the Nurse Practitioner, which included the medication change. The Director of Nursing and the Administrator were unaware of the discontinuation until after the resident's hospitalization. The facility lacked a triple-check process to ensure medication orders were correctly implemented, contributing to the oversight.
Failure to Implement Hearing Impairment Care Plan
Penalty
Summary
The facility failed to develop a person-centered care plan for a resident with hearing impairment. The resident, who was admitted to the facility with moderate cognitive impairment and minimal hearing difficulty requiring hearing aids, did not have a care plan addressing their hearing impairment. During an observation, the resident was found without their hearing aids, which were charging on the bedside table, and reported difficulty hearing without them. Interviews with facility staff revealed a lack of clarity and follow-through in implementing the resident's care plan. The MDS Nurse indicated that the Social Worker was responsible for implementing the care plan related to the resident's hearing impairment, but the Social Worker admitted to missing this aspect of the care plan. The Administrator confirmed that either the Social Worker or MDS Nurses were responsible for care plan implementation, but could not recall if the resident's hearing impairment care plan was reviewed in clinical meetings.
Failure to Secure Indwelling Catheter Tubing
Penalty
Summary
The facility failed to secure the indwelling urinary catheter tubing for a resident with a neurogenic bladder and urinary retention, leading to discomfort and potential risk of injury. The resident, who had moderate cognitive impairment, reported experiencing pain from the catheter when sitting in a chair, which was alleviated when a leg strap was used to secure the tubing. However, observations and interviews revealed that the catheter tubing was often left unsecured, and the leg strap was not consistently used or present in the resident's room. Interviews with staff, including a nurse aide and a nurse, indicated a lack of consistent adherence to the physician's order to check the catheter securement every shift. The nurse responsible for the resident admitted to forgetting to secure the catheter tubing on one occasion. The unit manager and the facility administrator both expressed expectations that the nursing staff would ensure the securement device was in place each shift, highlighting a gap between expected and actual practice in the facility's catheter care procedures.
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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