Wilora Lake Healthcare
Inspection history, citations, penalties and survey trends for this long-term care facility in Charlotte, North Carolina.
- Location
- 6001 Wilora Lake Road, Charlotte, North Carolina 28212
- CMS Provider Number
- 345473
- Inspections on file
- 22
- Latest survey
- April 24, 2026
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Wilora Lake Healthcare during CMS and state inspections, most recent first.
A resident who was cognitively intact and managed her own finances had her debit card information accessed by a former Business Office Manager while receiving assistance with a Medicaid application. Over several months, the former Business Office Manager used the resident’s debit card to make multiple unauthorized payments for personal credit cards, utilities, and internet service, totaling nearly $5,000. The misuse was not detected until after the employee resigned, when a Travel Business Office Manager reviewed historical bank statements for the Medicaid process and identified the suspicious transactions. The resident confirmed she had not authorized any of these charges and stated she would not have known about the missing funds without this review.
Staff failed to follow infection control policies for hand hygiene and Enhanced Barrier Precautions during high-contact care for a resident on EBP with a suprapubic urinary catheter. One NA performed suprapubic catheter and incontinence care, repeatedly changing gloves without performing required hand hygiene between glove changes. During separate incontinence and transfer-related care, two NAs donned gloves but did not wear gowns while cleaning the resident, assisting the resident to stand with a walker, repositioning the resident, and pulling the resident up in bed, despite posted EBP signage and available PPE. Both NAs later reported they were unaware that gowns were required for these high-contact activities, while nursing leadership stated they expected compliance with the facility’s hand hygiene and EBP policies.
A resident with multiple comorbidities, including type II DM, neurogenic bladder with suprapubic catheter, muscle weakness, and lymphedema, required substantial to maximal assistance with toileting hygiene and was frequently bowel incontinent. During observed suprapubic catheter care, a NA removed a visibly and odiferously soiled pull-up and, without cleansing the resident after the bowel movement, completed catheter care and applied a clean pull-up before covering the resident. The resident later reported she would have wanted to be cleaned, the NA admitted he had seen and smelled the stool but forgot to clean the resident due to nervousness about being observed, and the ADON acknowledged smelling the soiled pull-up and not intervening, while the DON stated she expected residents to be cleaned after bowel movements before clean briefs are applied.
A cognitively intact resident with an established goal of community discharge was sent home after active discharge planning and education on medication administration, but no written transfer or discharge notice was documented or provided, and no copy was sent to the Regional Ombudsman. The Ombudsman reported not receiving any transfer or discharge notices since the prior SW left, and interviews with former and current administrative, social services, and medical records staff showed that responsibilities for preparing and sending discharge notices were unclear and that no one recalled issuing or transmitting a notice for this resident.
A nurse aide failed to maintain privacy for a resident during incontinent care by leaving the room with the door open, exposing the unclothed resident to the hallway. The resident, who was dependent on assistance for daily living, expressed discomfort with being left exposed. Interviews confirmed that the facility's procedures require staff to ensure privacy by covering residents and closing doors during care.
A resident with cognitive impairment and a history of potential aggression struck another resident with a cane in their shared room, resulting in a raised red area on the victim's neck. The incident occurred after the victim re-entered the room to retrieve a personal item, despite the aggressor's known discomfort with others near his belongings. The facility failed to prevent this altercation, which led to harm.
The facility failed to document a thorough investigation into medication misappropriation involving two residents. A resident with hypertension and dementia was identified as affected when narcotics were found missing. Another resident with diabetes also had missing narcotics, but was not documented in the investigation report. Interviews revealed missing documentation, including narcotic count sheets and staff interviews, leading to the deficiency.
The facility inaccurately coded MDS assessments for two residents, leading to deficiencies in prognosis and discharge location. One resident under Hospice care was not coded for a prognosis of six months or less, while another resident's discharge to home was incorrectly recorded as a discharge to an acute hospital. Staff interviews revealed a lack of accurate documentation and communication regarding these assessments.
The facility failed to follow fall prevention and safe transfer protocols for three residents. Two residents, identified as fall risks, did not have fall mats in their rooms as required by their care plans. Another resident was improperly transferred using a mechanical lift by a single nurse aide, contrary to the care plan requiring two-person assistance. No injuries were reported, but the incidents highlighted a lack of adherence to safety protocols.
A nurse failed to disinfect a resident's glucometer according to guidelines, using an alcohol pad instead of EPA-approved wipes. Despite training, the nurse admitted to this practice, leading to a deficiency in infection control.
Two residents, both assessed as cognitively intact, were not given the opportunity to participate in the development or revision of their person-centered care plans. There was no evidence that these residents or their representatives were invited to care plan conferences or provided input following recent MDS assessments, and both the residents and their representatives did not recall being involved in such meetings. Documentation of invitations and attendance was missing for the relevant periods.
A resident with ESRD requiring dialysis did not have consistent documentation of post-dialysis access site assessments, including monitoring for infection, bleeding, and pain. Facility staff failed to complete required sections in both the dialysis communication form and EHR on multiple occasions, and communication with the dialysis center was not reliably maintained. Interviews with staff and leadership confirmed lapses in documentation and communication processes.
Misappropriation of Resident Funds by Former Business Office Manager
Penalty
Summary
The deficiency involves the facility’s failure to protect a cognitively intact resident’s personal funds from misappropriation by a former Business Office Manager. The resident, who was her own responsible party and handled her own finances, was admitted on an unspecified date and later required assistance from the facility with an ongoing Medicaid application. During the period in question, the former Business Office Manager had access to the resident’s financial information, including her debit card, in connection with this assistance. Record review of the resident’s bank statements showed that, between late September and late December, the former Business Office Manager used the resident’s debit card to make multiple unauthorized payments for the former Business Office Manager’s personal expenses. These included several credit card payments, a natural gas payment, and an internet service fee, totaling $4,945.62. The resident confirmed in interview that she had not given permission for the former Business Office Manager to use her debit card and stated that the charges were not authorized. She also reported that she would not have known any money was missing from her account if the Travel Business Office Manager had not reviewed her past bank statements for the Medicaid application. The misappropriation was discovered only after the former Business Office Manager had resigned from employment. When the Travel Business Office Manager assumed the former Business Office Manager’s duties related to the resident’s Medicaid application and reviewed several years of bank statements, she identified transactions made in the name of the former Business Office Manager over a defined three‑month period. This discovery led to notification of facility leadership and external agencies, and subsequent interviews with the resident and multiple staff confirmed that the resident’s funds had been wrongfully used for the former Business Office Manager’s personal bills. No other residents were identified as having unauthorized charges during the time the former Business Office Manager was employed, but the facility’s failure to prevent or detect the misuse of this resident’s debit card resulted in misappropriation of the resident’s personal funds.
Failure to Follow Hand Hygiene and Enhanced Barrier Precautions During High-Contact Care
Penalty
Summary
The deficiency involves failures in the facility’s infection prevention and control program, specifically related to hand hygiene and adherence to Enhanced Barrier Precautions (EBP). During an observation of suprapubic urinary catheter care for Resident #24, who was on EBP and had a suprapubic urinary catheter, NA #1 initially washed his hands with soap and water and donned a gown, face shield, and gloves. He prepared two basins of water and began care by removing the resident’s soiled brief and discarding it. After removing his gloves, NA #1 did not sanitize his hands before donning a clean pair of gloves to clean the suprapubic catheter with soaped washcloths. He again removed his gloves and, without performing hand hygiene, donned another clean pair of gloves to rinse the catheter and apply a new pull-up, only washing his hands with soap and water after all care and PPE removal were completed. The facility’s Hand Hygiene policy, last revised on 11/13/25, required staff to perform hand hygiene when indicated, including before applying and after removing PPE such as gloves, and specified alcohol-based hand rub as the preferred method in most clinical situations. NA #1 later acknowledged in interview that he had not followed appropriate hand hygiene practices, stating he forgot to sanitize his hands between glove changes despite carrying hand sanitizer in his pocket. The Assistant DON, serving as the Infection Preventionist, and the DON both stated they would have expected NA #1 to sanitize his hands each time he removed gloves before putting on clean gloves, consistent with the facility’s policy. A separate deficiency was identified regarding noncompliance with the facility’s EBP policy, also last revised on 11/13/25, which required gowns and gloves for high-contact resident care activities such as transferring and changing briefs. During an observation of incontinence care for Resident #24, NA #1 entered the room, donned gloves only, and performed incontinence care and assisted the resident to stand with a walker to complete cleaning and adjust the pull-up, without wearing a gown. After briefly leaving to obtain assistance, NA #1 and NA #2 returned, donned gloves but no gowns, and together repositioned the resident side to side to place a turn sheet and then pulled the resident up in bed using the turn sheet. Both NAs later stated they were not aware they were supposed to wear a gown for incontinence care, transferring, or adjusting a resident up in bed, despite the EBP sign and PPE caddie on the door. The Infection Preventionist and DON both indicated they would have expected gowns to be worn during these high-contact care activities for a resident on EBP.
Failure to Provide Toileting Hygiene Before Applying Clean Incontinence Brief
Penalty
Summary
The facility failed to provide toileting hygiene after a bowel movement before applying a clean pull-up for a resident who was dependent on staff for ADL assistance. The resident had type II diabetes mellitus, a neurogenic bladder with a suprapubic catheter, muscle weakness, and lymphedema, and her care plan included interventions related to impaired physical mobility and evaluation of her ability to perform ADLs. An admission MDS showed she was cognitively intact but required substantial to maximal assistance of one staff member for toileting hygiene, bed mobility, and transfers, and that she was occasionally incontinent of bladder and frequently incontinent of bowel. During an observed episode of suprapubic catheter care, a nurse aide removed the resident’s pull-up, which had visible brown substance and an odor of stool, and proceeded directly to perform catheter care without cleaning the resident. After completing catheter care, the aide placed a new pull-up on the resident and covered her without providing any toileting hygiene. The resident later stated she could not always tell when she had a bowel movement but would have wanted to be cleaned and preferred to be clean and free of stool odor. The aide acknowledged seeing and smelling the brown liquid substance on the pull-up and admitted he did not know why he had not cleaned the resident, stating he was nervous about being observed and had forgotten. The ADON, who was observing the procedure, reported she smelled the soiled pull-up and did not know why the aide had not cleaned the resident before putting on a clean pull-up, and the DON stated she expected staff to clean all residents after a bowel movement before applying clean pull-ups or briefs.
Failure to Provide Written Discharge Notice and Notify Regional Ombudsman
Penalty
Summary
The deficiency involves the facility’s failure to provide a written discharge notice to a resident being discharged home and to send a copy of that notice to the Regional Ombudsman. The resident was cognitively intact, had an overall goal of discharge to the community, and active discharge planning was underway with referrals made to a local contact agency. Nursing documentation showed that the resident was discharged home, was alert and oriented, and had medication administration explained, which she was able to repeat back, but there was no corresponding written transfer or discharge notice in the electronic medical record. Interviews with the Regional Ombudsman and multiple facility staff confirmed that no written transfer or discharge notice for this resident was issued or sent. The Regional Ombudsman reported not receiving any transfer or discharge notices, including for this resident, since the former social worker left several months earlier. The former administrator did not recall the resident or whether a written notice was given and stated that the former social worker, and later the former medical records coordinator, were responsible for sending notices to the Ombudsman. The former medical records coordinator stated that after the former social worker left, the former administrator handled social work tasks, that she did not recall this resident, and that she did not have access to any transfer or discharge notices to send. The current social worker and current administrator both started after the resident’s discharge and were not familiar with the case, with the administrator stating she expected a designated staff member would have provided the discharge notice and sent copies to the Regional Ombudsman.
Failure to Maintain Resident Privacy During Incontinent Care
Penalty
Summary
The facility failed to maintain personal privacy for a resident during incontinent care. A nurse aide left the room with the door open while the resident was unclothed and uncovered, making the resident visible from the hallway. This incident involved a resident who was cognitively intact but frequently incontinent and dependent on assistance for activities of daily living. The nurse aide did not cover the resident or close the door when she exited the room to retrieve gloves, leaving the resident exposed. Interviews with the resident, the nurse aide, a nurse, and the Director of Nursing confirmed the deficiency. The resident expressed discomfort and frustration with being left exposed, while the nurse aide acknowledged the oversight. The facility's standard procedure, as described by the nurse and the Director of Nursing, requires staff to ensure privacy by covering residents and closing doors when leaving the room during care. The administrator also emphasized the importance of maintaining privacy during incontinence care.
Resident-to-Resident Abuse Incident
Penalty
Summary
The facility failed to protect a resident's right to be free from abuse when a resident-to-resident incident occurred. Resident #20, who was moderately cognitively impaired and had a history of potential physical aggression, struck Resident #7 on the back of the head and neck with a metal cane. This incident happened after Resident #7 re-entered their shared room to retrieve a personal item, despite Resident #20's known discomfort with others near his belongings. Resident #7 sustained a raised red area on the back of his neck as a result of the attack. Resident #7 was admitted to the facility with diagnoses including type 2 diabetes and essential primary hypertension and was noted to be cognitively intact with no behavioral issues. In contrast, Resident #20 had diagnoses including end-stage renal disease and unspecified intellectual disabilities, with a care plan indicating a potential for physical aggression when parting with possessions. Despite these known risks, the facility did not adequately prevent the incident from occurring. The incident was reported immediately, and the residents were separated. Staff interviews revealed that Resident #20 had not previously exhibited this level of aggression, although he was known to become upset when others were near his belongings. The facility's social worker and Director of Nursing confirmed that Resident #7 was moved to a different room following the incident, and Resident #20 was sent to the hospital for evaluation. However, the report highlights a failure in preventing the initial altercation, which resulted in harm to Resident #7.
Incomplete Investigation of Medication Misappropriation
Penalty
Summary
The facility failed to maintain documented evidence of a thorough investigation into an allegation of misappropriation of medication for two residents. Resident #278, who was admitted with hypertension and non-Alzheimer's dementia, was identified as an affected resident when the facility became aware of a drug diversion allegation. The investigation report noted that a narcotic medication for Resident #278 was missing from the narcotic lock box. Nurse #6 was interviewed and suspended pending further investigation, while Nurse #7, who was also involved, did not report to work as scheduled and was unreachable. Despite these actions, the investigation documentation was incomplete, lacking narcotic count sheets, substance inventory count sheets, staff interviews, and audit sheets. Additionally, Resident #279, who had been diagnosed with Diabetes Mellitus, was also affected by the misappropriation, as noted by Nurse #8 during a narcotic medication count. However, there was no documentation related to Resident #279 in the facility's investigation report, and the state agency was not notified about this resident. Interviews with the former Administrator and the President of Clinical Operations revealed that they were unable to locate any further documentation related to the investigation, and the former DON claimed that all investigation information was left in the office. The lack of documentation and incomplete investigation led to the deficiency noted in the report.
Inaccurate MDS Coding for Prognosis and Discharge Location
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) assessments for two residents, leading to deficiencies in the areas of prognosis and discharge location. Resident #9, who was admitted with chronic obstructive pulmonary disease, chronic respiratory failure with hypoxia, and adult failure to thrive, was under Hospice care with a certified prognosis of six months or less. However, the MDS assessment did not reflect this prognosis accurately, as it was coded 'no' for a prognosis of six months or less. The previous MDS Coordinator stated that she did not have the certification of the prognosis at the time of coding, despite being aware that Hospice services had been initiated. Resident #73, admitted for short-term rehabilitation with a plan to discharge home, was inaccurately coded in the MDS as having been discharged to an acute hospital. The resident's electronic medical record indicated a discharge to home with family, and the Social Worker confirmed the discharge plan and execution. The traveling MDS Nurse, involved in discharge planning, was uncertain why the discharge location was inaccurately coded. The Administrator acknowledged that the MDS should accurately reflect the resident's discharge location.
Failure to Implement Fall Prevention and Safe Transfer Protocols
Penalty
Summary
The facility failed to implement fall prevention interventions as outlined in the care plans for Resident #5 and Resident #6, and did not provide a safe transfer for Resident #36 using a mechanical lift. Resident #6, who was admitted with diagnoses including cerebral infarction and dementia, experienced two falls within the facility. Despite being identified as a fall risk, observations revealed that a fall mat, which was part of the care plan, was not present in Resident #6's room. Interviews with staff and family confirmed the absence of the fall mat, indicating a lack of adherence to the care plan interventions. Resident #5, admitted with cerebrovascular accident and diabetes, also had a care plan that included the use of a fall mat due to a history of falls. However, multiple observations confirmed the absence of the fall mat in Resident #5's room. Interviews with staff revealed a lack of awareness regarding the requirement for a fall mat, and the Administrator acknowledged the oversight, suggesting it may have been removed during cleaning and not returned. Resident #36, with a chronic neurologic disorder, was involved in an incident where a mechanical lift was improperly used by a single nurse aide, contrary to the care plan that required two-person assistance. During the transfer, the lift tilted, causing the resident to slide off the bed. Although no injuries were reported, the incident highlighted a failure to follow established safety protocols. The Director of Maintenance later found a mechanical lift with a malfunctioning manual lever, but it was unclear if this was the lift used during the incident.
Improper Disinfection of Glucometer
Penalty
Summary
The facility failed to properly disinfect a resident's dedicated glucometer according to the manufacturer's guidelines, as observed during a medication pass. Nurse #3 was seen using an alcohol pad to clean the glucometer after monitoring Resident #69's blood sugar, instead of using the EPA-approved wipes as required. The nurse admitted to using alcohol pads for cleaning throughout the day, despite having completed the facility's online glucometer training upon hire. The Director of Nursing confirmed that the correct procedure involved using white top wipes with bleach and allowing a 3-minute dry time, which was not followed. The Administrator stated that all staff received training on the proper cleaning of glucometers, and the necessary supplies were available. However, the nurse's deviation from the protocol led to the deficiency in infection control practices.
Failure to Involve Residents in Care Plan Development and Revision
Penalty
Summary
The facility failed to ensure that residents were given the opportunity to participate in the development and revision of their person-centered care plans for two residents. For one resident with diagnoses including rheumatoid arthritis, frequent falls, depression, and chronic joint pain, there was no evidence in the electronic medical record that she was invited to attend care plan meetings or provide input regarding her care plan following two quarterly MDS assessments, despite being cognitively intact. The resident did not recall being invited to a care plan conference or having her goals discussed, and her representative also did not recall participating in any care plan conference. The last documented care plan conference for this resident was several months prior to the most recent MDS assessments, with no documentation of invitations or attendance for subsequent conferences. For another resident with peripheral vascular disease, atrial fibrillation, hypertensive heart disease, chronic kidney disease, moderate dementia, and depression, the care plan indicated impaired cognitive function but the most recent MDS assessment showed the resident was cognitively intact. The resident did not recall being invited to or attending a care plan conference, and the guardian reported not receiving invitations for recent conferences. The last documented care plan conference was several months prior, with no documentation of invitations or attendance for care plan conferences following more recent MDS assessments. The Social Services Director stated that the process involved notifying residents and representatives, but documentation was lacking for the relevant periods.
Failure to Document and Communicate Dialysis Care and Access Site Assessments
Penalty
Summary
The facility failed to maintain ongoing communication with the dialysis center and did not consistently document assessments of the dialysis access site post-dialysis for a resident with end stage renal disease who was dependent on dialysis. Despite physician orders and care plan interventions requiring regular assessment and documentation of the dialysis access site for signs of infection, bleeding, pain, and skin condition, multiple instances were found where the hemodialysis communication form and the electronic health record (EHR) were incomplete or missing required documentation for several dates. Staff interviews confirmed that while assessments were expected, documentation was not consistently completed in both the communication book and the EHR, particularly regarding the appearance of the access site and signs of infection. Further, the dialysis nurse reported that the communication book was not always received by the dialysis center, and that the facility staff did not always remove the bandage to assess the access site as required. The physician stated he relied on nursing staff to communicate any changes or new orders and did not review the dialysis communication forms. The Director of Nursing and Administrator confirmed the process for documentation and communication but acknowledged gaps in completion. These failures resulted in a lack of proper monitoring and communication regarding the resident's dialysis care.
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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