Autumn Care Of Marion
Inspection history, citations, penalties and survey trends for this long-term care facility in Marion, North Carolina.
- Location
- 1264 Airport Road, Marion, North Carolina 28752
- CMS Provider Number
- 345165
- Inspections on file
- 21
- Latest survey
- March 26, 2026
- Citations (last 12 mo.)
- 7 (1 serious)
Citation history
Health deficiencies cited at Autumn Care Of Marion during CMS and state inspections, most recent first.
A resident with dementia, hemiplegia, anxiety, and depression, who had shown months of increasing confusion, disorientation in hallways, and need for supervised smoking, exited the building unsupervised through a side door that did not alarm when opened and was not easily visible from the reception area. The resident self‑propeled in a wheelchair down the ramp, out of the parking lot, and into a busy two‑lane road, where a passerby and facility leadership found her in the roadway. Although leadership and the NP knew the resident had actually left the building, the DON’s documentation and verbal reports to multiple staff and a psychiatric provider described the event only as an "attempted elopement," leaving many staff unaware that the resident had been off premises in the road. Surveyors determined the facility failed to provide adequate supervision to prevent the unsupervised exit and failed to ensure staff were fully informed of the elopement.
The facility failed to maintain an accurate medical record when the DON documented that a resident had an “attempted elopement” and was “intercepted,” despite later stating in interview that the resident actually left the building and was found in the road past the gravel parking lot with altered, manic mentation and resisting efforts to return. A visitor alerted staff during a morning meeting that a resident was in the road, and the Administrator confirmed that staff then caught up to the resident, who had exited through a side door and was sitting in a wheelchair across the road. The Administrator expressed uncertainty about why staff did not recognize that the resident had fully eloped and questioned the discrepancy between the DON’s note and the actual circumstances, emphasizing an expectation that medical record entries be accurate.
The facility failed to submit required Level II PASRR evaluations for several residents who developed new or additional mental health diagnoses after admission or readmission. Each affected resident had a prior Level I PASRR indicating that paperwork should be resubmitted for Level II if new mental health conditions or significant changes occurred. Despite subsequent diagnoses such as PTSD, major depressive disorder, anxiety disorder, and psychotic disorders, documented as active on the MDS and in some cases treated with antidepressant and antipsychotic medications, there was no evidence that Level II PASRR requests were made. The SW and administrator confirmed the SW was responsible for PASRR submissions and acknowledged that Level II evaluations should have been completed for these residents based on their documented mental health conditions.
The facility failed to follow its abuse, neglect, and exploitation policy requiring immediate reporting and investigation when a pharmacy reported missing Oxycodone tablets from a sealed controlled medication return bag for a discharged resident. An ADON did not promptly return the pharmacy’s initial call, then delayed notifying the DON after being informed of the missing narcotics, and the DON further delayed notifying the Administrator. During this time, nurses associated with the narcotic returns continued to work, and notification to law enforcement about the missing narcotics was delayed and not clearly documented. These delays resulted in the Administrator not being immediately informed of the allegation of misappropriation of narcotic medication as required by facility policy.
A resident had a PRN oxycodone 5 mg order, with documentation showing several doses administered and seven tablets remaining at discharge. An RN completed a controlled substance return form and sealed the remaining oxycodone in a return bag without having a second nurse verify the medication, while another nurse signed the form without seeing or counting the drugs. A third nurse later released the sealed bag to the pharmacy driver after only confirming the bag’s serial number matched the pick-up ticket, without checking the contents. The pharmacy documented that no oxycodone was in the bag upon receipt and reported the discrepancy to facility staff, and the missing tablets were never located.
A resident was found with a bottle of 2% miconazole powder and a tube of 10% zinc oxide cream left in plain view on the bedside nightstand, despite no active physician orders for either medication. The resident reported that NA staff applied both products during incontinence care and that she did not self-administer them. An NA confirmed the items were house-stock medications used by staff and acknowledged they should not have been left in the room. The DON later stated these medications should have been stored on the treatment cart and that a physician order was required for their use.
A resident with a coccyx pressure wound did not have Enhanced Barrier Precautions (EBP) implemented as required by facility policy, as there was no EBP signage or PPE outside the room, and the Wound Care Nurse provided incontinence care and wound care wearing only gloves and no gown during high-contact activities. The Infection Preventionist had not placed the resident on the EBP list because she was unaware of the wound, and the nurse did not question the absence of precautions. Both the IP and DON later stated they would have expected the resident to be on EBP and the nurse to use a gown in addition to gloves during these care activities.
Unsupervised Elopement Through Non‑Alarming Side Door and Inadequate Staff Awareness
Penalty
Summary
The deficiency involves the facility’s failure to ensure the environment was free from accident hazards and to provide adequate supervision to prevent an unsupervised exit by a cognitively impaired resident. The resident had dementia, hemiplegia/hemiparesis following a cerebral infarction, anxiety, and depression, used a wheelchair, and required assistance with several ADLs. Staff, including multiple nurses and a nurse aide, reported that over several months prior to the incident the resident had experienced a decline with increased confusion, anxiety, disorientation in the hallways, difficulty finding her room, and forgetting that she required supervision to smoke. The resident’s care plan identified needs such as supervised leave of absence, variable mental function, risk for impaired vision, and risk for falls related to decreased mobility and muscle weakness, but there were no documented interventions for these care-planned problem areas. On the day of the incident, the resident was observed by staff and witnesses in her usual routine near the nurse’s station and front area, then left unsupervised and exited the building without staff knowledge. The DON and Administrator later determined that the resident exited through a side door that, at that time, did not have an alarm that sounded when opened and only had a wander management alarm that would activate if a wanderguard bracelet was present; the resident did not yet have such a device. This side door and the front door were the only exterior doors that did not alarm when opened, and the side door was the only door that could not be easily visualized by the receptionist. Staff in the morning meeting were unaware the resident had left until a visitor (Witness #2) entered the conference room and reported that a resident was in the road. Witnesses and staff described that the resident traveled down the ramp and out of the parking lot into a well-traveled two-lane road with blind curves and a posted speed limit of 35 mph. She was found in her wheelchair on the opposite side of the road from the facility, in the roadway, just past the gravel parking lot, attempting to self-propel further up the road. A passerby was present with the resident when staff arrived. The DON, ADON, Administrator, and other staff confirmed that the resident had actually left the building and was in the road, although the DON’s progress note and subsequent communication to several staff and the psychiatric provider characterized the event as an “attempted elopement” that had been intercepted by staff. Multiple staff members, including the assigned NA, several nurses, and the psychiatric provider, reported that they were only told it was an attempted elopement and did not know through the survey date that the resident had exited the building and gone down the road. The resident herself later stated she left the building in her wheelchair, went down the hill and up the road because she felt she needed to go home to care for her adult son, and she did not inform anyone she was leaving. The facility’s leadership, including the DON and Administrator, acknowledged awareness of the resident’s recent cognitive decline and that she had been changed from independent to supervised smoking due to increased confusion and difficulty holding a cigarette. They also acknowledged that prior to the incident the side door did not alarm when opened unless a wanderguard was present, and that the front door and side door were the only non-alarming exterior doors. The DON stated that he believed he had verbally informed all staff that the resident had actually left the facility and gone down the road, but he did not track who he told, and several staff and providers confirmed they were not informed of the full extent of the elopement. The Administrator stated she was not sure why all staff did not know that the resident had actually gotten out of the building and would need to speak with the DON about his progress note describing the event as an attempted elopement. The surveyors concluded that the facility failed to provide necessary supervision to prevent the resident from exiting unsupervised through a non-alarming side door and failed to ensure all staff were aware of the unsupervised exit. The report notes that the resident was not injured but that there was a high likelihood of serious harm, injury, or death, including risks of getting lost, falling without the ability to get out of harm’s way, or being hit by a car. The facility’s noncompliance was cited at Immediate Jeopardy level beginning on the date of the elopement, based on the unsupervised exit, the lack of an alarm on the side door, and the failure to ensure staff were aware of the actual elopement. Immediate Jeopardy was later removed after the facility implemented a credible allegation of immediate jeopardy removal, but the facility remained out of compliance at a lower scope and severity to ensure staff and providers were aware of the elopement and that education and monitoring systems were effective.
Removal Plan
- Returned Resident #1 to the facility without injury by the Administrator, Director of Nursing, and Assistant Director of Nursing
- Administrator and DON conducted an immediate review of the incident
- Administrator and DON determined the root cause was the side exit door lacked an alarm system that alerted staff when the door opened
- Administrator and DON contacted Resident #1's guardian, primary care provider, and Medical Director
- Resident #1's nurse completed a head-to-toe nursing assessment and found no injuries
- Administrator and DON interviewed Resident #1 regarding the incident and her stated desire to go home to care for her son
- Administrator reassured Resident #1 that her son is cared for by a full-time caregiver
- Director of Rehabilitation Services completed a BIMS assessment
- Resident #1's nurse completed an elopement risk assessment and identified Resident #1 as high risk for elopement
Inaccurate Documentation of Resident Elopement Event
Penalty
Summary
The deficiency involves the facility’s failure to maintain a complete and accurate medical record for a resident who left the building and was later found in the road. A progress note dated 3/2/26 at 10:30 AM, written by the DON, documented that the resident had an “attempted elopement” and was “intercepted,” and that reorientation to her situation was attempted without success. However, during interview, the DON stated that on the morning of 3/2/26, while management staff were in a morning meeting, a visitor entered the conference room and reported that a resident was outside. Management staff immediately left the meeting and located the resident on the road just past the gravel parking lot. The DON described the resident’s mentation as altered and “manic,” and reported that she was difficult to convince to return to the facility as she continued to try to propel her wheelchair further up the hill, stating she needed to take care of her son. The DON acknowledged in interview that the resident did in fact elope and was found down the road below the gravel parking lot, and he was unable to explain why he had documented in the progress note that the elopement was only attempted and that the resident was intercepted by staff. In a separate interview, the Administrator confirmed that during the same morning meeting a visitor reported a resident in the road, and that staff then caught up to the resident, who was across the road from the facility, just past the gravel parking lot, sitting in her wheelchair in the road. The Administrator stated the resident had exited via a side door and expressed uncertainty as to why all staff did not know the resident had actually gotten out of the building. The Administrator also questioned why the DON’s progress note characterized the event as an attempted elopement and stated that she expected all information entered into a resident’s medical record to be accurate.
Failure to Request Level II PASRR Evaluations After New Mental Health Diagnoses
Penalty
Summary
The deficiency involves the facility’s failure to submit required Level II Preadmission Screening and Resident Review (PASRR) evaluations for multiple residents who developed new or additional mental health diagnoses after admission. For each of the five affected residents, a PASRR Level I had been completed prior to admission with explicit recommendations to resubmit paperwork for a Level II evaluation if a new mental health diagnosis was suspected or if there was a significant change in condition. Despite these instructions, the medical records for these residents contained no evidence that Level II PASRR requests were submitted after new mental health diagnoses were made and documented. One resident was initially admitted with medical diagnoses such as hypertension and diabetes and later readmitted with new diagnoses of post-traumatic stress disorder (PTSD) and major depressive disorder, which were documented as active on the MDS, yet no Level II PASRR request was found. Another resident was admitted with Parkinson’s disease, heart failure, and multiple mental health conditions including anxiety disorder, major depressive disorder, and a psychotic disorder with hallucinations; these diagnoses were active on the MDS, and the resident had received antidepressant and antipsychotic medications in the prior seven days, but again there was no evidence of a Level II PASRR request. A third resident, originally admitted with heart failure, diabetes, and seizure disorder, was later readmitted with new diagnoses of anxiety disorder, major depressive disorder, and psychotic disorder with delusions, all active on the MDS, without any corresponding Level II PASRR submission. Two additional residents had similar patterns of new or additional mental health diagnoses without subsequent Level II PASRR requests. One was readmitted with a new diagnosis of major depressive disorder, which was active on the MDS, and another, long-term resident with dementia and hypertension was readmitted with new diagnoses of major depressive disorder, PTSD, and anxiety disorder, all active on the MDS, yet neither had documentation of a Level II PASRR request. Interviews with the social worker and the administrator confirmed that the social worker was responsible for completing and submitting PASRR paperwork, that she had only recently received training, and that they were unaware these residents lacked Level II evaluations despite the presence of qualifying mental health diagnoses and prior Level I instructions to resubmit for Level II upon such changes.
Failure to Immediately Report and Investigate Missing Narcotic Medication
Penalty
Summary
The deficiency involves the facility’s failure to follow its Abuse, Neglect and Exploitation policy requiring immediate reporting of all allegations and suspicions of misappropriation of resident property, including narcotics, to the Administrator/Abuse Coordinator. The policy stated that once notified, the Administrator/Abuse Coordinator would immediately begin an investigation and notify applicable local and state agencies. In this case, the facility became aware through the pharmacy that seven 5 mg tablets of Oxycodone, a narcotic pain medication belonging to Resident #134 and contained in a sealed Controlled Medication Return Bag, were missing after the resident had been discharged. This information was first relayed to the facility on 4/10/2025 when pharmacy staff attempted to contact the facility about an issue with narcotic medication that was supposed to be returned. According to interviews, the ADON was informed on 4/10/2025 by a floor nurse that the pharmacy was on the phone regarding an issue with narcotic medication sent back to the pharmacy, but when the ADON got to the phone, the pharmacy was no longer on the line and she did not attempt to call the pharmacy back. The pharmacy called again on 4/11/2025 and informed the ADON of the missing Oxycodone for Resident #134. The ADON did not notify the DON of the missing narcotics until 4/12/2025, stating she did not know missing narcotics had to be reported immediately and wanted to wait to see if the pharmacy could locate the medication. The DON then delayed notifying the Administrator until 4/14/2025 because he did not know that missing narcotics was a reportable event that required immediate notification and investigation. As a result, the Administrator was not informed of the allegation of misappropriation until several days after the facility first became aware of the missing narcotics. During this period of delayed reporting and investigation, nursing staff who were later identified in the facility’s investigation as involved in the handling of the narcotic returns continued to work. Time records showed that one nurse worked multiple overnight shifts from 4/12/2025 through 4/15/2025, and another agency nurse worked shifts spanning 4/10/2025 through 4/12/2025 after the ADON had been notified by the pharmacy of the missing Oxycodone and before the facility initiated its investigation. Law enforcement notification was also delayed and not clearly documented. The facility’s Initial Allegation Report listed that a police officer was called on 4/15/2025, but the officer reported there were no records of any calls or emails from the facility regarding missing narcotics during that time, and the DON’s call log only showed a call to the officer’s direct number on 4/18/2025. These actions and inactions demonstrate that the facility did not follow its own abuse, neglect, and exploitation policy for immediate reporting and investigation of suspected misappropriation of resident property.
Failure to Account for and Return Controlled Oxycodone Medication
Penalty
Summary
The deficiency involves the facility’s failure to maintain effective systems for the return, disposition, and accurate accounting of a resident’s controlled medication, specifically oxycodone 5 mg prescribed PRN for pain. The resident was admitted with an order for oxycodone 5 mg every 6 hours as needed and received a total of four doses in March and one dose in April, after which no further administrations were documented. The controlled substance count record showed that seven oxycodone tablets remained after the last documented dose on April 1, and the resident was discharged the following day with those seven tablets still on hand. On April 7, a Controlled Substance Prescription Returned to Pharmacy form was completed indicating that the seven remaining oxycodone tablets were being returned to the pharmacy in a sealed Controlled Medication Return Bag. Nurse #1 reported that he prepared the resident’s oxycodone for return and took the return form to Nurse #2 for signature without bringing the narcotic cards for verification. He acknowledged leaving the medication unattended in the medication room while obtaining the second nurse’s signature and stated that Nurse #2 did not participate in verifying the medications. Nurse #1 then placed the narcotic cards, including the card with seven oxycodone tablets, into the return bag, sealed it himself, and stored it in the locked narcotic drawer. Nurse #2 confirmed she signed the form without verifying the medications or having access to them and later recognized she should not have signed without confirming the contents. On April 8, Nurse #3 and the pharmacy driver signed the pharmacy pick-up slip, verifying only that the serial number on the sealed Controlled Medication Return Bag matched the serial number on the pick-up ticket. Nurse #3 stated she did not verify the contents of the sealed bag at the time of pick-up. The Pharmacist in Charge explained that the pharmacy’s process required matching the bag’s serial number to the pick-up ticket and checking that the seal was intact, but did not require verification of the bag’s contents by the driver. When the pharmacy processed the return on April 9, the pharmacy’s copy of the Controlled Substance Prescription Returned to Pharmacy form included a handwritten note stating that the medication was not in the bag and that the pharmacy had called the facility twice about the issue. The Pharmacist in Charge confirmed that the seven oxycodone tablets never arrived at the pharmacy and stated that the facility remained responsible for following up on the missing medication. Interviews with the ADON, DON, and Administrator confirmed that the missing oxycodone tablets were never found and that the facility’s process at the time relied on serial number verification rather than verification of the actual controlled substances being returned.
Unsecured House-Stock Topical Medications Left in Resident Room Without Physician Order
Penalty
Summary
The deficiency involves unsecured medications and lack of physician orders for topical drugs used for a resident. Resident #59 had no active physician orders for 2% miconazole antifungal powder or 10% zinc oxide protective cream, according to a review of the physician orders. During an observation of the resident’s room, surveyors noted a 3-ounce bottle of 2% miconazole powder and a 2.75-ounce tube of 10% zinc oxide cream in clear view on the nightstand beside the bed. The resident stated that nurse aide staff applied both products during incontinence care and that she did not wish to self-administer either medication. During an interview and observation, a nurse aide assigned to the hall entered the room, saw the miconazole powder and zinc oxide cream on the nightstand, and identified them as facility house stock. The nurse aide confirmed that staff applied these products during incontinence care but acknowledged they should not have been left in the resident’s room and removed them. In a subsequent interview, the DON, with the Administrator present, stated that the miconazole powder and zinc oxide cream were supposed to be stored on the treatment cart and not left in the resident’s room, and further explained that a physician’s order was required if the resident needed these products.
Failure to Follow Enhanced Barrier Precautions During Wound and Incontinence Care
Penalty
Summary
The deficiency involves the facility’s failure to follow its Enhanced Barrier Precautions (EBP) policy for a resident with a coccyx pressure wound. The facility’s policy, revised on 05/19/2025, required staff to don both gloves and a gown for high-contact activities, including incontinence care and wound care, for high-risk residents such as those with wounds. Surveyor observations on two consecutive days showed that there was no EBP signage on the resident’s door and no PPE available outside the room, despite the resident reporting she had a sore on her bottom that was dressed daily. During a wound care observation, the Wound Care Nurse entered the room with wound care supplies in gloved hands, placed them on the bed sheet, and provided incontinence care and wound care without donning a gown at any point. Interviews revealed that the resident had not been placed on the Infection Preventionist’s EBP list because the Infection Preventionist was not aware the resident had a coccyx pressure wound. The Wound Care Nurse stated that the resident was not on the list of those requiring EBP and therefore no precautions had been implemented, although she thought it was odd the resident was not on precautions and did not question it. The Infection Preventionist stated she would have expected the Wound Care Nurse to wear a gown while providing incontinence and wound care, and the DON similarly stated he would have expected the resident to be on EBP and the Wound Care Nurse to use both gloves and a gown during care. These actions and omissions resulted in noncompliance with the facility’s EBP policy for infection prevention and control.
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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