Willow Creek Nursing And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Goldsboro, North Carolina.
- Location
- 2401 Wayne Memorial Drive, Goldsboro, North Carolina 27534
- CMS Provider Number
- 345113
- Inspections on file
- 25
- Latest survey
- March 19, 2026
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Willow Creek Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
Surveyors found that food items in the walk-in cooler, including a container of pudding and a pan of turkey sandwiches, were stored without labels or dates. The Dietary Manager reported that these items were not present before the weekend and must have been prepared and stored during that time, but the exact timing could not be determined due to missing labels and dates. She stated that she and the Assistant Dietary Manager monitor for unlabeled items during the week, but no one is assigned this responsibility on weekends, and that staff who place food in the cooler are responsible for labeling and dating it. The Administrator confirmed that there should be no unlabeled or undated food items in the walk-in cooler.
Surveyors identified that the facility failed to maintain clean and properly maintained privacy curtains, medical equipment, and walls in several rooms occupied by severely cognitively impaired residents. In one room, a privacy curtain remained in use despite multiple dark brown/red stains, even though the assigned housekeeper was responsible for replacing soiled curtains. In another room, an oxygen concentrator had visible white particles on its surface on repeated observations, despite a housekeeping schedule that required weekly cleaning and additional cleaning when dirty. In a third room, blood-like drips were present on a wall where a resident’s scabbed knee rested; the NA reported the wall had not been cleaned for at least two weeks and did not notify housekeeping, and the housekeeper stated she only noticed and cleaned the stains the day before the interview.
A resident with dementia, ESRD on HD, diabetes, and anticoagulant therapy was care-planned as totally dependent for transfers and required a mechanical lift. After returning from HD and repeatedly requesting to go to bed, a NA, unable to access a charged lift, attempted a stand-pivot transfer despite knowing a lift was required. The resident’s legs gave out, resulting in an assisted fall to the floor; the NA then lifted the resident back into a wheelchair and later, with another NA and a medication aide, manually transferred the resident to bed without notifying an RN/LPN or obtaining a nurse assessment. Only after the transfer and onset of right shoulder pain was the unit manager notified, and later that evening a nurse identified a large, painful chest wall swelling that led to hospital evaluation and diagnosis of a large right chest wall hematoma with active bleeding.
A resident who was totally dependent for transfers and required a mechanical lift per the care guide returned from dialysis, requested to go to bed due to pain and fatigue, and was assisted by a CNA who found nearby lifts uncharged. Despite knowing a lift was required, the CNA attempted a stand-pivot transfer without a lift, during which the resident’s legs gave out and she was lowered to the floor. Without notifying a nurse, the CNA manually lifted the resident from the floor back into a wheelchair and later, with another CNA and a medication aide, manually lifted the resident from the wheelchair to the bed, again without a lift, while the resident was slumped and at risk of falling. After these transfers, the resident complained of right shoulder pain and was later found to have a large, painful chest wall swelling; hospital evaluation identified a large right chest wall hematoma with active arterial bleeding, and the Medical Director indicated the injury was more likely related to how the resident was transferred than to the assisted fall itself.
A resident was transported to the hospital and admitted for an intestinal obstruction without the responsible party being notified by the facility. The resident, who was moderately cognitively impaired, requested transport to the emergency room. Despite receiving a status update from the hospital, the facility staff failed to inform the responsible party, who only learned of the situation from the hospital social worker.
A resident with a history of falls and recent fall incidents did not have a comprehensive care plan addressing fall risk. The MDS nurse acknowledged the oversight, and both the DON and Administrator were unaware of the missing care plan.
Two residents in the facility did not receive their prescribed Ozempic injections due to the medication being unavailable on multiple occasions. Despite the missing doses, the physician and nursing staff reported no negative outcomes for the residents. The facility's Director of Nursing emphasized the importance of administering medications as prescribed.
A nurse in an LTC facility failed to follow infection control procedures during tracheostomy care for a resident with chronic respiratory failure. The nurse did not perform hand hygiene between glove changes, used contaminated sterile gloves, and utilized a dropped q-tip to clean the tracheostomy site. The resident required complete assistance with daily living activities, including tracheostomy care, and was at risk for ineffective breathing patterns.
A nurse in an LTC facility failed to perform tracheostomy care using proper sterile techniques, as observed during a survey. The nurse did not perform hand hygiene between glove changes and used a dropped q-tip to clean around the tracheostomy stoma. Discrepancies were found in the training provided, as the nurse claimed she was not trained until after the observation, contrary to the facility's statements.
A resident with a history of hemiplegia and back surgery experienced discomfort due to a sagging mattress. Despite a work order and staff awareness, the mattress was not replaced, leading to continued discomfort. Observations confirmed the mattress's poor condition, but the facility failed to take timely action.
Two residents in an LTC facility did not receive their prescribed Ozempic medication due to it being documented as unavailable on multiple occasions. Despite the pharmacy delivering the medication, it was reported as lost, and the facility had to reorder it at their own expense. The facility's investigation revealed discrepancies in medication administration records and packing slips, indicating potential misappropriation or misplacement of the medication.
A resident with impaired vision was mistakenly given ear drops in her eyes by a nurse in orientation, leading to a significant medication error. Despite the resident's concerns about blurry vision, medical evaluations determined the ear drops did not cause vision changes. The facility's investigation involved staff interviews and education on proper medication administration routes.
Unlabeled and Undated Food Items Stored in Walk-In Cooler
Penalty
Summary
Surveyors observed that the facility failed to label or date food items stored in the walk-in cooler, contrary to professional standards and facility expectations. During a kitchen tour, an unlabeled and undated rectangular metal container covered with plastic wrap was found to contain approximately 10 ounces of pudding, and an additional unlabeled and undated metal sheet pan covered with aluminum foil was found to contain about 20 turkey sandwiches. The Dietary Manager stated that when she left at 4:00 PM on the preceding Friday, neither the pudding nor the sandwiches were present in the cooler and that they must have been prepared and placed there over the weekend, but she could not determine exactly when due to the lack of labels and dates. She reported that she and the Assistant Dietary Manager monitored the walk-in cooler for unlabeled or undated food items during the week, but no one was designated to perform this monitoring on weekends, and that whoever placed food in the cooler was responsible for labeling and dating it. The Administrator confirmed in an interview that there should be no unlabeled or undated food items in the walk-in cooler. No specific residents or their medical conditions were mentioned in the report, and the deficiency was described as having the potential to affect food served to residents.
Failure to Maintain Clean Curtains, Equipment, and Walls in Resident Rooms
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe, clean, and comfortable environment in multiple resident rooms. In one room on the 300 hall, a severely cognitively impaired resident’s privacy curtain closest to the window was observed on two separate dates with multiple dark brown/red stains. The assigned housekeeper, who was responsible for replacing soiled or stained privacy curtains, acknowledged that the curtain needed to be changed but could not explain why it had not been replaced earlier in the week. The Housekeeping Manager stated that housekeepers were responsible for changing curtains when soiled or stained and agreed that the curtain should have been changed as soon as the markings were noticed. In another room on the 200 hall, a severely cognitively impaired resident’s oxygen concentrator was observed on two separate dates with visible white particles all over the top surface. The housekeeper assigned to that room confirmed that it was her responsibility to wipe down oxygen concentrators in resident rooms and acknowledged that she had not noticed that the concentrator needed to be cleaned prior to the surveyor’s observation. The Housekeeping Manager reported that oxygen concentrators and other medical equipment in resident rooms were supposed to be cleaned weekly and additionally whenever dirty, dusty, or soiled, and that this concentrator should have been cleaned during the scheduled cleaning. In a third room on the 200 hall, a severely cognitively impaired resident was observed lying in bed with his left knee bent and resting on the wall, where dark red marks in a dripping pattern were present. A nurse aide identified the drippings as blood and showed the resident’s knee with three scabbed areas, stating that the wall had not been cleaned since she started working at the facility two weeks earlier. She did not notify housekeeping about the blood stains and could not provide a reason, stating she “just did not think about it.” The housekeeper later reported that she only noticed and cleaned the dark red marks on the wall the day before the interview, and the Housekeeping Manager stated that daily room cleaning was expected to include wiping down vertical and horizontal surfaces, including walls, and that the stains should have been noticed and cleaned during routine cleaning.
Failure to Follow Fall Protocol and Transfer Requirements After Assisted Fall
Penalty
Summary
The deficiency involves the facility’s failure to follow fall protocol and the resident’s care plan by not notifying a nurse immediately after an assisted fall and by moving the resident before a licensed nurse assessment. The resident involved had dementia, ESRD on hemodialysis, diabetes, portal vein thrombosis treated with Eliquis, and an aneurysm of the upper extremity artery. Her MDS and care plan specified that she was totally dependent for transfers and required a one-person mechanical lift with a medium sling for all transfers. On the day of the incident, the resident returned from dialysis, ate lunch, and repeatedly requested to be put to bed due to feeling tired and hurting, which staff reported was usual after dialysis. Around mid-afternoon, NA #1 went to transfer the resident to bed. NA #1 knew from the Resident Care Guide that a mechanical lift was required but found that the two lifts on her section were not charged and unavailable. Despite this and the resident’s insistence on going to bed, NA #1 attempted a stand-pivot transfer from the wheelchair to the bed without a lift. During this attempt, the resident’s legs gave out, she panicked, and NA #1 lowered her to the floor. NA #1 then independently lifted the resident from the floor back into the wheelchair, where the resident appeared slumped, and adjusted her upright. NA #1 did not notify a nurse at the time of the assisted fall and did not obtain a nurse assessment before moving the resident from the floor to the wheelchair. Shortly thereafter, NA #1 called NA #2 and the Medication Aide to help transfer the resident from the wheelchair to the bed but did not inform them that an assisted fall had occurred. All three staff lifted the resident from the wheelchair to the bed using manual assistance. The Medication Aide later stated she did not call a nurse because she had not witnessed a fall and only saw the resident slumped in the wheelchair. After the transfer to bed, the resident complained of right shoulder pain and requested pain medication, which was administered. The Unit Manager was then notified and, upon arrival, found the resident already in bed, reporting 10/10 right shoulder pain. The Unit Manager and DON later confirmed that facility protocol required that residents not be moved after a fall until a licensed nurse assessed them, and that NA #1, NA #2, and the Medication Aide should not have transferred the resident before that assessment. Later that evening, another nurse noted a large, painful swelling on the resident’s right upper chest, and the resident was sent to the ED, where imaging showed a large right chest wall hematoma with active bleeding.
Failure to Use Required Mechanical Lift and Report Assisted Fall Leads to Hematoma After Manual Transfers
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s environment was free from accident hazards and that adequate supervision and assistive devices were used during transfers, as required by the resident’s care plan and Resident Care Guide. The resident had dementia, ESRD on hemodialysis, diabetes, was cognitively intact, and was totally dependent on staff for transfers. Her care plan and Resident Care Guide, implemented and revised prior to the incident, specified that she required a one-person assist with a mechanical lift for all transfers, with a medium sling. She was also receiving Eliquis, an anticoagulant that increases the risk of bruising and bleeding, and had an as-needed order for oxycodone for pain. On the day of the incident, the resident returned from dialysis around midday, ate lunch, and requested to be put to bed because she was tired and hurting, which staff reported was usual for her after dialysis. Nursing Assistant (NA) #1, who was passing meal trays, told the resident she would assist after meal service. When NA #1 later attempted to retrieve a mechanical lift, she found that the two lifts in her assigned section did not have any charge. NA #1 informed the resident she would have to wait longer because the lifts were not available, but the resident was adamant about being transferred to bed immediately. Around 2:45 PM, despite knowing from the Resident Care Guide that the resident required a mechanical lift for all transfers, NA #1 decided to accommodate the request and attempted a stand-pivot transfer from the wheelchair to the bed without using a lift. During this attempted manual transfer, the resident’s legs gave out, she began to panic, and she put her full weight on NA #1, who then lowered her to the floor. NA #1 did not notify a nurse at that time and, instead of leaving the resident on the floor for assessment, manually lifted her from the floor back into the wheelchair by placing her arms under the resident’s arms and her knees against the resident’s knees. The resident appeared slumped in the wheelchair, and NA #1 pulled her more upright. NA #1 then called for help without disclosing the assisted fall. NA #2 and the Medication Aide responded; seeing the resident slumped and appearing at risk of falling from the wheelchair, they, together with NA #1, manually lifted the resident from the wheelchair to the bed without a mechanical lift, with two staff at the upper body and one at the legs. After being placed in bed, the resident complained of right shoulder pain and requested pain medication. Later that evening, a large, painful swelling was observed on the right upper chest, and hospital evaluation documented a large, tense right chest wall hematoma with active bleeding, ultimately diagnosed as an arterial hemorrhage requiring interventional radiology embolization and subsequent surgical hematoma evacuation. The Medical Director stated that the hematoma more likely resulted from how the resident was transferred, including pressure applied under the armpits, rather than from the fall itself.
Failure to Notify Responsible Party of Resident's Hospitalization
Penalty
Summary
The facility failed to notify the responsible party (RP) of a significant change in a resident's condition, which included transport and admission to the hospital. The resident, who was initially cognitively intact upon admission, was later assessed as moderately cognitively impaired with a diagnosis of delirium. On the night of the incident, the resident requested to be transported to the emergency room and was subsequently admitted to the hospital for an intestinal obstruction. Despite this significant change, the RP was not informed by the facility and only learned of the situation from the hospital social worker two days later. Interviews with facility staff revealed a breakdown in communication and responsibility. Nurse #1, who was responsible for the resident's discharge to the hospital, did not notify the RP, and Nurse #2, who later received a status update from the hospital, also did not inform the RP, assuming it was Nurse #1's responsibility. The facility's Director of Nursing and Administrator acknowledged the oversight, indicating that the hall nurse should have notified the RP of the resident's transport and hospital admission.
Failure to Develop Comprehensive Fall Risk Care Plan
Penalty
Summary
The facility failed to develop a comprehensive care plan addressing fall risk for a resident who was admitted with a history of falling, unspecified fracture of the lower end of the left radius, and unspecified dementia. A review of the resident's Minimum Data Set (MDS) indicated a fall in the previous 30 days, yet the comprehensive care plan lacked a section on fall risk. During an interview, the MDS nurse acknowledged the absence of a falls risk care plan, attributing it to an oversight. The Director of Nursing (DON) confirmed that the MDS nurse was responsible for developing comprehensive care plans and was unaware of the missing falls risk care plan. The Administrator also stated she was not aware of the deficiency.
Medication Administration Errors for Ozempic
Penalty
Summary
The facility failed to ensure that two residents received their prescribed Ozempic subcutaneous injections as ordered, resulting in medication errors. Resident #116, who was admitted with a diagnosis of diabetes mellitus, had orders for Ozempic to be administered weekly. However, the Medication Administration Record (MAR) indicated that the medication was not available on multiple occasions, specifically on 4/30/24, 5/7/24, and 5/14/24. Interviews with the nursing staff revealed that they did not recall the incidents but mentioned standard procedures for handling unavailable medications, such as contacting the physician and pharmacy. The pharmacist confirmed that the Ozempic pen dispensed for Resident #116 was reported lost by the facility, and a replacement was provided on 5/15/24. Similarly, Resident #163, also diagnosed with diabetes mellitus, had orders for Ozempic to be administered weekly. The MAR showed that the medication was unavailable on 4/24/24, 5/1/24, 5/8/24, and 5/15/24. Interviews with the nursing staff involved indicated a lack of recollection of the specific incidents but outlined the usual protocol for addressing unavailable medications. The pharmacist reported that the Ozempic pen dispensed for Resident #163 was also reported lost, and a replacement was provided on 5/16/24. The physician involved was aware of the missing Ozempic pens and noted that while the medication was not critical for daily blood sugar control, it was important for stabilizing hemoglobin A1C over time. Despite the medication errors, the physician and nursing staff reported no negative outcomes for the residents due to the lack of Ozempic. The Director of Nursing emphasized that medications should be administered as prescribed, highlighting the facility's expectation for adherence to medication orders.
Infection Control Breach in Tracheostomy Care
Penalty
Summary
The facility failed to adhere to professional standards of practice and infection prevention measures during the provision of respiratory care to a resident with a tracheostomy. The incident involved a nurse who did not perform hand hygiene between the removal of soiled gloves and the application of sterile gloves. Additionally, the nurse touched the outside of the tracheostomy packaging with sterile gloves and did not change them, and used a sterile q-tip that had been dropped onto the resident's nightgown to clean the tracheostomy site. The nurse also contaminated the new sterile inner cannula by touching it with gloves that had contacted the outside of the tracheostomy tray. The resident involved was admitted with acute and chronic respiratory failure with hypoxia, a history of neoplasm of the nasal cavity and mid ear, and a chronic tracheostomy. The resident was cognitively intact and required complete assistance with all activities of daily living, including tracheostomy care. The care plan indicated a risk for ineffective breathing patterns related to the tracheostomy. Interviews with the nurse, the Staff Development Coordinator, the Director of Nursing, the Administrator, the infection preventionist, and the Nurse Practitioner revealed a lack of adherence to infection control procedures. The nurse acknowledged the errors and the importance of maintaining sterile technique to prevent respiratory infections. The facility staff emphasized the necessity of hand hygiene and proper glove use to prevent contamination during tracheostomy care.
Nurse Competency Deficiency in Tracheostomy Care
Penalty
Summary
The facility failed to ensure that a nurse was competent in providing tracheostomy care for a resident. During an observation, Nurse #4, who was an agency nurse, performed tracheostomy care without adhering to proper sterile techniques. She donned sterile gloves without performing hand hygiene after removing soiled gloves, touched the outside of the tracheostomy care tray with sterile gloves, and used a q-tip that had been dropped on the resident's clothing to clean around the tracheostomy stoma. Additionally, she opened the inner cannula package with sterile gloves, which compromised the sterility of the procedure. Interviews revealed discrepancies in the training provided to Nurse #4. The Staff Development Coordinator (SDC) claimed to have completed hands-on tracheostomy training with all nurses, including Nurse #4, before they worked with the resident. However, Nurse #4 stated that she did not receive this training until after the observation. The Director of Nursing and the Administrator also stated that new nurses, including agency nurses, were trained on tracheostomy care before working with the resident, but this was contradicted by Nurse #4's account.
Failure to Replace Damaged Mattress
Penalty
Summary
The facility failed to replace a damaged bed mattress for a resident, leading to discomfort and potential exacerbation of existing medical conditions. The resident, who was cognitively intact and had a history of right-sided hemiplegia, neuropathy, and back surgery, reported feeling like he was lying in a hole due to the sagging mattress. Despite a work order being placed by a medication aide, the mattress was not replaced with a new one, and the resident continued to experience discomfort. Interviews with staff revealed a breakdown in communication and follow-through regarding the replacement of the mattress. The maintenance assistant referred the work order to the central supply manager, who claimed to replace old mattresses if they were in poor condition. However, the central supply manager did not recall replacing the mattress for the resident, and the maintenance director confirmed that the work order was marked as completed without a new mattress being provided. Observations confirmed the poor condition of the mattress, with visible sagging and wear. The resident's family member and a nurse also noted the mattress's poor condition, and the nurse stated that it should be replaced. Despite these observations and complaints, the facility did not take timely action to address the resident's concerns, resulting in the resident sleeping on an uncomfortable and potentially harmful mattress for an extended period.
Misappropriation of Diabetes Medication in LTC Facility
Penalty
Summary
The facility failed to protect two residents from the misappropriation of their medication, specifically Ozempic, which is used to manage diabetes mellitus. Resident #116 was prescribed Ozempic to be administered once a week, but the medication was documented as unavailable on multiple occasions, including 4/23/24, 4/30/24, 5/7/24, and 5/14/24. Despite the pharmacy delivering the medication, it was reported as lost, and the facility had to reorder it at their own expense. Interviews with nursing staff revealed a lack of recollection regarding the incidents, and the facility's initial response did not identify the issue as misappropriation. Similarly, Resident #163 experienced a similar issue with their Ozempic medication. The medication was documented as unavailable on 4/24/24, 5/1/24, 5/8/24, and 5/15/24, despite being delivered by the pharmacy. The facility's investigation revealed discrepancies in the medication administration records and packing slips, indicating that the medication was not administered as prescribed. The facility was unable to determine the location of the missing medication, leading to the conclusion that it was either misplaced or misappropriated. The facility's failure to ensure the availability and administration of prescribed medications resulted in a deficiency related to the misappropriation of resident property. The investigation highlighted issues with the facility's medication management processes, including inadequate tracking and documentation of medication availability and administration. The facility's inability to substantiate the misappropriation of the medication further underscores the need for improved oversight and accountability in medication handling and administration.
Medication Error: Ear Drops Administered in Eyes
Penalty
Summary
The facility failed to ensure that ear drop medication was administered via the correct route, resulting in a significant medication error for a resident. The resident, who was cognitively intact but had impaired vision, was mistakenly given ear drops in her eyes by a nurse who was still in her orientation period. The nurse, while orienting with another nurse, brought both eye and ear drops into the resident's room and handed the ear drops to the resident, who then administered them into her eyes. Despite attempts to stop the resident, the medication had already been administered incorrectly. The incident was reported to the Director of Nursing (DON) and the resident's physician, who instructed that the resident's eyes be flushed with saline. The resident expressed concern about the incident, reporting blurry vision afterward, although two separate eye examinations concluded that the ear drops did not cause any vision changes. The resident was dissatisfied with the explanations provided by the medical professionals and believed the blurry vision was a result of the medication error. Interviews with the involved staff revealed discrepancies in their accounts of the incident. The nurse who administered the medication denied the error, while another nurse observed the administration but could not confirm which drops were used. The facility's consultant pharmacist and the resident's physician both indicated that the ear drops could cause mild irritation but not lasting vision damage. The facility's investigation did not identify a trend of incorrect ear drop administration, and education was provided to the involved nurse regarding proper medication administration routes.
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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