Autumn Care Of Salisbury
Inspection history, citations, penalties and survey trends for this long-term care facility in Salisbury, North Carolina.
- Location
- 1505 Bringle Ferry Road, Salisbury, North Carolina 28146
- CMS Provider Number
- 345269
- Inspections on file
- 27
- Latest survey
- April 2, 2026
- Citations (last 12 mo.)
- 6
Citation history
Health deficiencies cited at Autumn Care Of Salisbury during CMS and state inspections, most recent first.
Surveyors found that the facility failed to properly label and date multiple food items stored in the walk-in freezer, including french fries, chicken breasts, sausages, hush puppies, baguettes, gluten-free bread, and a chocolate cream pie. Some items had been removed from original packaging and placed in resealable bags without any labeling, while others in original packaging lacked open or expiration dates. The Dietary Manager stated all freezer items should be labeled and dated when opened or repackaged, and staff had been educated on these requirements. A cook’s assistant and a cook reported performing weekly freezer audits, but one focused only on expired items and did not check labeling, and audits were not documented. The Administrator reported she was unaware that open food items were not being properly dated, although a prior audit had already identified unlabeled or uncovered items in the freezer.
The facility failed to secure cords from wall‑mounted televisions in multiple rooms on one hall after a grievance reported that the cords posed a tripping hazard. An audit identified numerous rooms needing cord securement, and a purchase order for cord securement kits was approved, but subsequent surveyor observations found that televisions in several rooms still had power and auxiliary cords hanging 2–3 feet off the floor, with slack that required being pushed aside to pass between the bed and the cords. The Maintenance Director acknowledged awareness of the issue and ordering kits but could not recall their installation or status, and the Administrator reported she had been informed by a prior Administrator that investigations were completed and corrections made, and was unaware that the cords remained unsecured.
A resident’s advance directive and code status were not documented consistently throughout the EHR and care plan. The resident was initially admitted as full code, but after a hospitalization, hospital documentation and an active physician order reflected DNR status. Despite this, the care plan, Care Conference Summary, and EHR demographic tab continued to list the resident as full code. The POA reported the resident’s preferences had changed over time and believed the resident was full code, while the Social Worker, MDS Nurse, and NP reported that during a care plan meeting the POA agreed the resident would remain DNR. The Social Worker acknowledged she did not update the care plan or EHR code status at the time of the meeting, leading to the discrepancy, and leadership staff were unaware that the physician order and other documentation did not match.
Two residents with gastrostomy tubes were affected by failures in tube feeding practices. For one resident with severe cognitive impairment, surveyors observed a soiled bag in the room containing two used enteral feeding tube decloggers with dried residue, despite manufacturer labeling that the devices were single-use only; staff interviews showed inconsistent understanding, with some nurses believing the decloggers could be reused. For another cognitively intact resident who received all nutrition via tube feeding and had diabetes, the MAR reflected an order and documentation for Diabetasource 1.2 at a continuous rate, but observation showed that IsoSource 1.5 was actually infusing. The nurse who hung the feeding reported she assumed IsoSource and Diabetasource were equivalent because they were made by the same manufacturer, and therefore did not follow the specific physician order for the diabetic-appropriate formula.
A resident with a suprapubic catheter had an after-visit summary and nursing note indicating a required follow-up urology appointment for routine catheter replacement, but this appointment was not communicated to the Transportation Coordinator and was never scheduled. The resident later reported that the catheter had not been changed since the initial urology visit and complained of lower abdominal soreness, believing it was related to the overdue catheter change. A nurse documented the resident’s concerns, contacted the Transportation Coordinator to arrange a new appointment, and offered a PRN catheter change, which the resident refused, preferring the urologist. The urologist subsequently confirmed that the resident had missed the scheduled follow-up and stated that monthly catheter replacement was necessary to prevent infection and tissue breakdown, and that missing the appointment placed the resident at high risk for harm. The acting DON and Administrator reported they were unaware of the missed appointment, and the Administrator noted that an agency nurse may not have followed the established process for notifying the Transportation Coordinator about follow-up visits.
A resident with dementia and hemiplegia repeatedly indicated that a male NA had hit her face, while multiple staff and the resident’s representative observed her crying and noted redness, swelling, or possible bruising on one side of her face. Staff reported the allegation to the Administrator and Unit Manager and wrote statements, but no abuse allegation or related assessment was documented in the medical record, and the NP, SW, ADON, and DON were not promptly notified or formally involved. The Administrator briefly questioned the resident, demonstrated how an arm might rest against the resident’s jaw during incontinence care, concluded the allegation was not valid due to the resident’s cognition, did not submit a 24‑hour abuse report, and did not suspend or interview the alleged perpetrator, who continued working multiple shifts. These actions and inactions show the facility did not follow its abuse policy for immediate reporting, investigation, documentation, and protection of the resident after an abuse allegation.
The facility failed to label and date leftover food, remove spoiled items, and prevent staff food storage in resident nourishment room refrigerators. Observations revealed unlabeled and undated food items, including croutons, strawberries, blueberries, and a microwavable dinner tray with signs of spoilage. Additionally, a container of cream of mushroom soup with an expired discard date was found in the walk-in cooler. Staff responsible for daily checks admitted to lapses in protocol.
Three residents did not receive their scheduled showers due to miscommunication involving an agency NA, who was incorrectly informed that no showers were scheduled for the hall. This led to the residents' preferences being disregarded, causing them distress.
Two residents receiving enteral feedings had their syringes improperly stored with plungers inside, risking bacterial growth. Nurses were unaware of the correct storage procedure, which was confirmed by the DON and acknowledged by the Administrator.
The facility failed to maintain clean air intake filters on oxygen concentrators for two residents requiring oxygen therapy. Observations revealed significant dust accumulation on the filters, and staff interviews indicated confusion over cleaning responsibilities. The DON and Administrator confirmed that nursing staff should clean the filters weekly, but this was not being done.
A resident with Parkinson's Disease experienced a grievance related to medication administration that was not promptly resolved by the facility. The resident's Responsible Party filed a grievance expressing concerns about the unavailability of medications and preferred email communication, which was not accommodated by the facility. The DON's attempts to contact the Responsible Party by phone were unsuccessful, and the Administrator did not pursue the grievance further, leaving the issue unresolved.
A resident with cognitive impairments became agitated during care, leading to an incident where one nurse aide allegedly slapped the resident while another held the resident's hands. The resident, who had a history of aggressive behavior, was not protected according to their care plan, resulting in a deficiency in safeguarding the resident from abuse.
A resident in a LTC facility was subjected to inappropriate handling by two NAs during care. The resident, who was combative and verbally abusive, had their hands restrained by one NA, while the other allegedly slapped the resident on the thigh. The incident was not reported immediately, allowing the NAs to continue their shift, contrary to the facility's abuse policies.
A resident with Parkinson's disease was not transported to a scheduled neurologist appointment due to a transportation conflict at the facility. The family member had informed the facility of the appointment in advance, but alternative transportation could not be arranged, resulting in a significant delay in the resident's care. The facility's physician believed the missed appointment did not impact the resident's care, but the family member was upset about the delay.
A resident with Parkinson's disease did not receive their prescribed Carbidopa-Levodopa medication due to unavailability. Despite efforts by nursing staff to notify the pharmacy and the Director of Nursing, the medication was not delivered on time, resulting in missed doses. The Physician's Assistant and Director of Nursing were unaware of the issue, and no hold order was documented, leading to a deficiency in care.
A resident with Parkinson's disease did not receive six doses of Carbidopa-Levodopa due to medication unavailability. Despite efforts by nursing staff to resolve the issue, the medication was not delivered promptly, and there was a lack of communication and documentation regarding hold orders. The Physician's Assistant noted potential impacts on the resident's health, although no immediate harm was reported.
Improper Labeling and Dating of Frozen Food Items
Penalty
Summary
Surveyors identified a deficiency in the facility’s food storage practices in the walk-in freezer, where multiple food items were not labeled or dated in accordance with professional standards. During an initial kitchen tour with the Dietary Manager, surveyors observed a bag of french fries and a package of 25 chicken breasts that had been removed from their original packaging and placed into resealable plastic bags without any labeling, open dates, or expiration dates. Three sausages were also found removed from original packaging, placed in an unlabeled resealable plastic bag with no open or expiration date, and had visible ice crystals. Additional items in original packaging lacked required dating, including a bag of hush puppies, a bag of 30 baguettes, two packages of gluten-free bread that were only labeled with an open date but no expiration date, and a chocolate cream pie with no expiration date. In interviews, the Dietary Manager stated that all food items stored in the freezer should be labeled and dated when opened or when removed from original packaging, and discarded once expired, and that staff had previously been in-serviced on these requirements. The Cook’s Assistant reported she performed weekly freezer checks for expired items and labeling, but also stated that these audits were not documented and that a second-shift staff member had completed the prior week’s freezer audit. The Cook reported she rotated freezer audit responsibilities with the Cook’s Assistant and that, during the previous week, she checked only for expired food items and did not check for improperly labeled items, despite having received education on proper food storage and labeling. The Administrator stated she was not aware that open food items were not being labeled with appropriate dates and reported that a prior audit had already identified unlabeled or uncovered food items in the freezer.
Unsecured Wall-Mounted Television Cords Creating Tripping Hazard in Multiple Rooms
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe, easy-to-use, and comfortable environment by not securing cords from wall‑mounted televisions in multiple resident rooms on the 600 hall. A grievance filed on 4/30/25 reported that television cords from wall‑mounted televisions posed a tripping hazard. On 5/5/25, a purchase order for ten cord securement kits was approved by the former Administrator, and an in‑service education form from the same date documented that the former Administrator instructed the Maintenance Director that, although the television cords were not considered a safety concern, they should be kept close to the wall by a cord securement system or by tying up the cords. An audit completed by the Maintenance Director on 5/7/25 identified 38 rooms, including rooms 603, 604, 605, 606, 607, 608, and 609 on the 600 hall, as needing television cord securement. Despite this, surveyor observations on 3/30/26 and again on 4/2/26 showed that rooms 603, 604, 605, 606, 607, 608, and 609 still had loose television cords hanging from wall‑mounted televisions. The televisions were mounted approximately 6 feet high, with two cords hanging down and remaining 2 to 3 feet off the ground: a power cord plugged into the wall about 2 feet from the floor and an auxiliary cord dangling freely with several feet of slack between the television and a cable box. The cords hung in such a way that they had to be pushed aside to pass between the end of the bed and the cords. During interview, the Maintenance Director stated he recalled ordering the cord securement kits after the grievance and audit but did not recall installing them, did not know whether they were backordered or received, and had no completed work order for their installation. The current Administrator, who started in June 2025, reported she had been told by the former Administrator that investigations were completed and corrections made and stated she was not aware that the television cords had not been secured.
Inconsistent Documentation of Resident Code Status and Advance Directive
Penalty
Summary
The deficiency involves the facility’s failure to maintain accurate and consistent documentation of a resident’s advance directive and code status across the medical record. The resident was initially admitted as a full code, and the electronic health record (EHR) banner and care plan dated 1/9/2026 reflected full code status. The resident was later hospitalized and then readmitted, with hospital documentation and an active physician’s order dated 01/17/2026 indicating a Do Not Resuscitate (DNR) status. Despite this, multiple areas of the facility’s documentation, including the care plan, Care Conference Summary, and the demographic tab in the EHR, continued to list the resident as full code. The resident’s quarterly MDS showed severely impaired cognition, and interviews with the resident’s Power of Attorney (POA) revealed that the resident had changed preferences over time, initially choosing DNR during a hospitalization and later expressing a desire to be full code after returning to the facility. The POA stated he informed facility staff that the resident should be full code and believed the code status remained full code, and he was unaware that the code status was documented as DNR following readmission. The POA also recalled a care plan meeting in the current year but could not remember whether code status was discussed. Interviews with staff showed conflicting understandings and incomplete follow-through on documentation responsibilities. The Social Worker reported that the resident returned from the January 2026 hospitalization as DNR and that during the 01/23/2026 care plan meeting, attended by the POA, MDS Nurse, and herself, the code status was discussed and remained DNR per the POA. She acknowledged that the discrepancy between the DNR physician order and the full code entries in the care plan, Care Conference Summary, and EHR demographic tab occurred because she did not update the code status at the time of the meeting and typically completed updates days later. The MDS Nurse stated that during the same meeting the POA requested the resident remain DNR and that she informed the NP, who also reported that the POA wanted the code status to remain DNR. The Regional Nurse Consultant acting as DON and the Administrator both stated they were unaware of the discrepancy and that the expectation was that the EHR, physician orders, and care plan be consistent and updated immediately when an advance directive is initiated, changed, or maintained.
Improper Reuse of Single-Use Decloggers and Incorrect Tube Feeding Formula Administration
Penalty
Summary
Surveyors identified that single-use enteral feeding tube declogging devices were being retained and apparently reused for a resident with a gastrostomy tube, contrary to manufacturer instructions. One resident with severe cognitive impairment and a history of gastrostomy tube use was observed lying in bed with tube feeding infusing, and a soiled clear plastic bag hanging on the wall behind the head of the bed contained two long, thin plastic declogging stylets with dried tan feeding residue. The manufacturer's package in the bag clearly stated the declogger was intended for single use only. A nurse present at the time reported that night-shift staff were responsible for maintaining the decloggers and that they were used for one week, and she did not remove the soiled decloggers during that observation. On a subsequent observation, the previously seen soiled decloggers were no longer present, and the nurse reported she had removed and discarded them and hung new supplies. Multiple staff interviews revealed inconsistent understanding of the decloggers' proper use: some nurses stated they always used a new declogger and discarded it immediately after use, while another nurse who worked nights stated she believed the devices were reusable and would need to ask how many times they could be reused. The Central Supply Manager confirmed that only single-use decloggers were stocked and pointed out the manufacturer’s warning label that they should be discarded after a single use. The Unit Manager, Nurse Practitioner, and Interim DON each stated they were unaware that staff had been retaining or reusing single-use decloggers and affirmed that staff were expected to follow manufacturer instructions. Surveyors also found that another resident with a gastrostomy tube, who was cognitively intact and received all nutrition and hydration via the tube, was not administered the tube feeding formula specified in the physician’s order. The resident’s order required Diabetasource 1.2 at 80 ml/hr over 20 hours daily, with documentation on the MAR. The MAR showed that the ordered Diabetasource 1.2 feeding was signed out as started, but observation revealed the resident was actually receiving IsoSource 1.5 at 80 ml/hr, as labeled on the feeding container. The nurse who hung the feeding stated she believed IsoSource and Diabetasource were equivalent because they were from the same manufacturer and, based on that assumption, hung IsoSource 1.5 instead of the ordered Diabetasource 1.2. The Registered Dietitian and Medical Director later confirmed there are differences between the two formulas and that Diabetasource 1.2 was the appropriate formula for the resident’s diabetes diagnosis.
Failure to Schedule and Complete Ordered Urology Follow-Up for Suprapubic Catheter
Penalty
Summary
The deficiency involves the facility’s failure to ensure a follow-up urology appointment was scheduled and completed as ordered for a cognitively intact resident with a suprapubic catheter. The resident was admitted with a suprapubic catheter that had been changed by a urologist, with written instructions in the hospital urology after-visit summary for a routine catheter replacement on 02/10/2026. Nurse documentation on the day of the hospital visit also noted that the suprapubic catheter was changed and that the resident was to return for a urology follow-up appointment on that date. However, the Transportation Coordinator reported that she was not made aware of any February follow-up appointment, had no copy of an after-visit summary highlighting a February appointment, and therefore did not schedule it. The last appointment she had documented was the initial urology visit when the catheter was changed. The resident later reported that the suprapubic catheter had not been changed since the initial urology visit and stated he had informed a nurse about the February appointment, though he could not recall which nurse. He complained of lower abdominal soreness, which he believed was related to the catheter not being changed in over a month. A nurse’s progress note documented that the resident voiced concerns about the catheter not being changed and requested a urology appointment, and that the nurse left a message for the Transportation Coordinator to arrange it. The resident had a PRN order for catheter change, and the nurse offered to change it, but the resident refused, preferring the urologist to perform the procedure. The urologist later confirmed that the resident had been scheduled for a catheter replacement on 02/10/2026 but did not attend, and that the catheter required monthly replacement to prevent infection and tissue breakdown, stating that missing the appointment placed the resident at high risk for harm. The acting DON and the Administrator both stated they were not aware of the missed appointment, and the Administrator noted that the agency nurse involved may not have been aware of the process for notifying the Transportation Coordinator.
Failure to Implement Abuse Reporting and Investigation Procedures After Resident Allegation
Penalty
Summary
The deficiency involves the facility’s failure to implement its abuse policy and procedures for reporting, investigating, and protecting a resident after an allegation of abuse. The facility’s written policy required that all allegations, suspicions, and incidents of abuse, neglect, involuntary seclusion, exploitation, misappropriation of property, and injuries of unknown origin be immediately reported to the Administrator/Abuse Coordinator, that an investigation be initiated immediately, that applicable state and local agencies be notified, and that any accused staff member be removed from resident care and placed under supervision pending the outcome of the investigation. The policy also required notification of the resident’s responsible party and attending physician, documentation of assessments and notifications in the medical record, and involvement of social services when appropriate. The resident involved was readmitted with hemiplegia, diabetes, and dementia and was assessed as moderately cognitively impaired, with clear but sometimes difficult speech, adequate vision and hearing, and a need for substantial assistance with toileting and bed mobility. On the morning after a night shift, multiple staff members, including the Activities Director, Activities Assistant, Environmental Supervisor, and nursing assistants, independently encountered the resident crying, upset, patting the left side of her face, and repeatedly saying “hit-hit” or similar phrases, sometimes naming a male staff member. Several staff observed the resident’s left cheek as pink, swollen, or puffy, and one NA reported seeing a bruise under the left eye. These staff documented handwritten statements and reported the allegation to the Administrator and Unit Manager. The resident’s representative also observed the resident upset with a pink cheek and reported that the resident indicated she had been hit. Despite these reports, the medical record contained no nursing notes documenting an allegation of abuse, and the nurse assigned to the resident on the day of the allegation stated she was told by the DON not to worry about charting because the DON would take over the investigation. The Unit Manager and another nurse reported performing skin assessments, but documentation was delayed or absent, and the Unit Manager stated she was waiting for direction from the Administrator regarding documentation. The Administrator, after a brief interaction with the resident in which she physically demonstrated how an arm might rest against the resident’s jaw during incontinence care and asked if that was what happened, concluded the allegation was not valid due to the resident’s cognitive status, did not treat it as an abuse allegation, did not suspend the alleged perpetrator, and did not complete or submit an initial 24‑hour abuse report to state agencies. The alleged staff member continued to work multiple 12‑hour shifts, was never interviewed or asked for a written statement about the incident, and social services, the NP, ADON, and DON were not promptly or formally engaged in a documented investigation. Several leaders, including the DON and ADON, later reported that they had been told by the Administrator that the incident was already determined to be related to incontinence care and that the investigation was complete, and the HR Director reported that staff were upset that an investigation had not been completed in the manner they expected. These actions and omissions demonstrate the facility’s failure to follow its own abuse policy regarding immediate reporting, thorough investigation, documentation, and protection of the resident after an allegation of abuse.
Failure to Properly Label, Date, and Store Food Items
Penalty
Summary
The facility failed to properly label and date leftover food items, remove spoiled food, and prevent staff food from being stored in resident nourishment room refrigerators. During an observation in the 600 Hall nourishment room refrigerator, a bag of croutons was found unlabeled and undated, along with a quart-sized sealed plastic bag containing strawberries and blueberries that showed discoloration and a fuzzy white substance. Additionally, a microwavable dinner tray with meat and broccoli was observed with discoloration and a fuzzy substance, and an unlabeled and undated plastic container contained a white substance resembling mold. Nurse Aide #4 admitted to placing her lunch bag in the fridge, acknowledging it should not be there. Both Nurse Aide #4 and Nurse Aide #5 were responsible for checking the nourishment rooms daily to ensure items were labeled, dated, and discarded appropriately. In the kitchen, a container of leftover cream of mushroom soup with a discard date that had already passed was found in the walk-in cooler. The Dietary Manager admitted the soup should have been discarded and was missed during checks. The Dietary Manager also revealed that Dietary Aide #1 was responsible for checking nourishment rooms over the weekend but was unavailable for an interview. The Administrator confirmed the expectation that nourishment rooms be checked daily and that food items be stored and labeled correctly.
Failure to Honor Resident Shower Preferences
Penalty
Summary
The facility failed to honor the shower preferences of three residents, all residing on the 200 hall, on 2/28/25. Resident #32, who was moderately cognitively impaired, expressed that choosing between a shower and a sponge bath was very important. Despite being scheduled for a shower on that day, she did not receive one, which upset her. Similarly, Resident #77, also moderately cognitively impaired, did not receive her scheduled shower and expressed her dissatisfaction. Resident #24, who was cognitively intact, also did not receive her scheduled shower and was upset as she expected to be offered one later in the day. The issue arose due to a miscommunication involving Nursing Assistant (NA) #3, an agency staff member who was reassigned to the 200 hall on the day in question. NA #3 reported being informed by other staff that there were no showers scheduled for the hall, leading her not to offer showers to the residents. The Director of Nursing confirmed that NA #3 received inaccurate information and that the residents should have been offered showers as per their preferences. The Administrator also confirmed the expectation that residents receive showers on their scheduled days if they desire them.
Improper Storage of Enteral Feeding Syringes
Penalty
Summary
The facility failed to properly store enteral feeding syringes for two residents, leading to potential bacterial growth and contamination. Resident #44, who was admitted with diabetes and difficulty swallowing, received a significant portion of her nutrition and fluids through enteral feedings. Observations on two consecutive days revealed that her enteral feeding flush syringe was stored with the plunger inside the syringe, which contained a thick white liquid. Nurse #1, responsible for administering medication and flushes, was unaware that the syringe should be stored separately from the plunger to prevent bacterial growth. Similarly, Resident #65, admitted with dementia and difficulty swallowing, also received a significant portion of her nutrition and fluids through enteral feedings. Observations showed that her enteral feeding flush syringe was stored improperly with the plunger inside. Nurse #2, who was about to use the syringe, was also unaware of the correct storage procedure. The Director of Nursing confirmed that the syringes should be washed and stored with the plunger separated to allow drying and prevent bacterial growth. The Administrator acknowledged the oversight by the nursing staff.
Failure to Maintain Clean Oxygen Concentrator Filters
Penalty
Summary
The facility failed to maintain clean air intake filters on oxygen concentrators for two residents, both of whom required oxygen therapy due to respiratory conditions. Resident #34, who was cognitively intact, was observed with an oxygen concentrator that had a significant layer of black dust on the air intake filter. This condition persisted over multiple observations, and staff interviews revealed a lack of clarity regarding who was responsible for cleaning the filters. Nurse #1 was unaware of the cleaning responsibilities, and the Director of Nursing indicated that the assigned nurse should clean the concentrators weekly. Similarly, Resident #44, who was moderately cognitively impaired, was also observed with a dusty air intake filter on her oxygen concentrator. Interviews with Nurse #1 and the Housekeeping Supervisor further highlighted the confusion over cleaning duties, with the Housekeeping Supervisor stating that nursing staff were responsible. The Administrator confirmed that nursing staff should clean the machines and filters at least weekly, yet this was not being done, leading to the deficiency.
Failure to Resolve Grievance Regarding Medication Administration
Penalty
Summary
The facility failed to promptly resolve a grievance filed on behalf of a resident with Parkinson's Disease, who was admitted to the facility in June 2022. The grievance was filed by the resident's Responsible Party, who expressed concerns about the resident's medication administration, specifically the unavailability of Parkinson's medications. The grievance was assigned to the Director of Nursing (DON) on the same day it was filed, but the DON documented unsuccessful attempts to contact the Responsible Party by phone, and the grievance remained unresolved. The Responsible Party reported that he had communicated his concerns through email to the Social Worker (SW) and verbally to other staff members, including the floor nurse and care planner, but received no resolution. He preferred email communication due to his busy schedule, but the facility did not accommodate this preference. The DON was unaware of the Responsible Party's preference for email communication until after her attempts to reach him by phone, and she did not follow up with an email. The Administrator and the DON did not effectively coordinate to address the grievance. The Administrator believed that email was not an appropriate medium for discussing grievances and did not attempt to contact the Responsible Party. The grievance process was further complicated by the transition of responsibilities to a new social worker, SW #2, who was not involved in handling the grievance. As a result, the facility did not make prompt efforts to resolve the grievance, leaving the Responsible Party's concerns unaddressed.
Failure to Protect Resident from Abuse During Care
Penalty
Summary
The facility failed to protect a resident's right to be free from staff-to-resident abuse. During an incident involving two nurse aides providing care to a cognitively impaired resident, the resident became agitated and combative. One of the nurse aides, NA #7, allegedly slapped the resident on the left upper thigh, while the other aide, NA #6, held the resident's hands to prevent further aggression. This incident was reported by NA #6, who stated that the resident had been aggressive and used racial slurs during the care process. The resident involved in the incident was admitted with multiple diagnoses, including cerebral infarction, major depressive disorder, and dementia, and required extensive assistance for mobility and transfers. The resident's care plan indicated a risk of adjustment issues and potential for aggressive behavior, with interventions in place to approach the resident calmly and report any mood changes. Despite these interventions, the resident's behavior during the incident was combative, and the aides continued care without following the protocol to walk away when residents are combative. The incident was reported to the facility administration, and an investigation was conducted. Statements from the involved staff members revealed discrepancies in their accounts of the event, with NA #7 denying any aggressive behavior. The facility's Director of Nursing and Administrator were informed of the incident, and NA #7 was removed from the floor pending investigation. The report highlights a failure in adhering to the resident's care plan and the facility's protocol for handling combative behavior, resulting in a deficiency in protecting the resident from abuse.
Failure to Report and Address Resident Abuse
Penalty
Summary
The facility failed to adhere to its abuse policies concerning identification, protection, and reporting, as evidenced by the incident involving Resident #3. During the incident, Nurse Aide (NA) #6 and NA #7 were providing care to Resident #3, who became combative and verbally abusive. Despite the resident's aggression, NA #6 restrained Resident #3's hands, and NA #7 allegedly slapped the resident on the thigh. Neither NA intervened or reported the incident immediately, allowing both aides to continue working their shift, potentially putting other residents at risk. The facility's policy requires immediate reporting of any suspected abuse, neglect, or mistreatment, and mandates the removal of the accused staff member from resident care areas. However, NA #6 did not report the incident until several hours later, and NA #7 continued to work until she was removed from the floor by Nurse #7. The delay in reporting and failure to follow protocol highlights a significant lapse in the facility's abuse prevention and reporting procedures. Resident #3, who was not cognitively intact and had a history of being combative, was subjected to inappropriate handling by the staff. The incident was not addressed promptly, and the staff involved did not follow the established guidelines for managing combative behavior, such as walking away or seeking assistance. This deficiency in handling the situation and reporting it in a timely manner reflects a breach in the facility's duty to protect its residents from abuse and ensure their safety.
Failure to Transport Resident to Neurologist Appointment
Penalty
Summary
The facility failed to ensure that a resident with Parkinson's disease was transported to a scheduled neurologist appointment. The resident, who was admitted to the facility with a diagnosis of Parkinson's disease, was supposed to attend a neurologist appointment for medication adjustments and therapy recommendations. The family member of the resident had informed the facility of the appointment in advance, but two days before the appointment, the facility notified the family member that they could not provide transportation. This resulted in the appointment being rescheduled to a later date, causing a significant delay in the resident's care. The Transporter, who was responsible for the facility's transportation, realized a week before the appointment that she could not transport the resident due to a scheduling conflict. Attempts to arrange alternative transportation through a contracted company were unsuccessful as they were fully booked. The facility's Director of Nursing and Administrator acknowledged the transportation conflict and the failure to arrange alternative transportation, but the facility's physician believed the missed appointment did not impact the resident's care. Despite this, the family member was upset about the delay in the resident's neurologist visit.
Failure to Administer Prescribed Medication
Penalty
Summary
The facility failed to ensure that a resident with Parkinson's disease and a neurocognitive disorder with dementia received their prescribed medication, Carbidopa-Levodopa, as ordered by the physician. The resident was admitted with a physician's order for Carbidopa-Levodopa to be administered four times a day. However, on multiple occasions, the medication was not available for administration. On 11/10/2024, Nurse #7 discovered the medication was not available and notified the Director of Nursing and the pharmacy. Despite these efforts, the pharmacy indicated the medication would not be sent until a week later. The nurse documented the missed doses and informed the Physician's Assistant, but no hold order was given. Further issues occurred on 11/11/2024 and 11/20/2024, where the medication was again unavailable, and doses were missed. Nurse #6 documented that the medication was on hold, but no physician's order was found to support this action. Interviews with the Physician's Assistant and the Director of Nursing revealed a lack of communication and awareness regarding the unavailability of the medication. The Director of Nursing stated that the nursing staff should have ensured the medication was sent promptly and notified the provider, but this did not occur, leading to the deficiency.
Failure to Administer Essential Parkinson's Medication
Penalty
Summary
The facility failed to ensure that a resident with Parkinson's disease was free from significant medication errors. The resident was not administered six doses of Carbidopa-Levodopa, a medication critical for managing Parkinson's disease symptoms. The medication was ordered to be given four times a day, but due to unavailability, the doses were missed on multiple occasions. The issue began when a nurse discovered that the medication was not available and could not be obtained from the facility's electronic emergency medication system. Despite notifying the Director of Nursing and the pharmacy, the medication was not delivered promptly. The pharmacy indicated that a 'Refill Too Soon' form was needed before the medication could be sent. The nurse documented the unavailability of the medication and the ongoing efforts to resolve the issue, but the medication remained unavailable for several doses. Interviews with the nursing staff, Physician's Assistant, and the Director of Nursing revealed a lack of communication and documentation regarding the hold orders for the medication. The Physician's Assistant and the Director of Nursing were not aware of the missed doses, and there was no documented order to hold the medication. The Physician's Assistant acknowledged that the missed doses could have affected the resident's mobility, breathing, and swallowing, although no immediate harm was reported. The Director of Nursing stated that the nursing staff should have ensured the medication was available and notified the provider promptly.
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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