Barbour Court Nursing And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Smithfield, North Carolina.
- Location
- 515 Barbour Road, Smithfield, North Carolina 27577
- CMS Provider Number
- 345237
- Inspections on file
- 29
- Latest survey
- February 26, 2026
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Barbour Court Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
Surveyors found that MDS assessments were inaccurately coded for several residents regarding medication use and pneumococcal vaccination status. One resident’s insulin injections were underreported in the MDS compared to the MAR, while another resident receiving a non-insulin injectable for diabetes was incorrectly coded as receiving insulin. A third resident was coded as receiving anticoagulants despite no corresponding orders or MAR entries. Additionally, a resident with only a single historical PPSV23 dose documented was incorrectly coded as having up-to-date pneumococcal vaccination, with the MDS nurse later acknowledging she had relied on outdated CDC guidance.
A resident with DM II had a physician order for Novolog 10 units SQ with meals, to be held if blood sugar (BS) was less than 150, yet a nurse documented multiple BS readings below 150 and still administered the full insulin dose on several mornings. The nurse later reported she did not recall any BS parameters for the insulin and believed such parameters would appear on the electronic MAR. The resident was cognitively intact and regularly received insulin injections, while the NP, DON, and Administrator all acknowledged that insulin should be administered according to ordered parameters and that giving insulin outside those parameters constitutes a serious medication error.
The facility failed to ensure residents’ right to timely access to their mail, including delivery on the day it was received and on Saturdays. Multiple residents reported that regular mail, including magazines and catalogues, was inconsistently delivered and often sat for days in the activities room, sometimes for about a week, before being given to them or picked up. Staff interviews revealed that the receptionist retrieved and sorted mail on weekdays and typically did not sort Saturday mail until Monday, after which it was placed in the activities room for activities staff to deliver. The Activities Director stated that activities staff were expected to sort and deliver mail daily but acknowledged that some items, such as bills, might be held until the receptionist could review them. The Administrator stated he expected daily mail delivery, including Saturdays, and was unaware of delays or concerns because no grievances had been submitted.
The facility failed to include a resident's POA document in the medical record and did not provide advance directive education or opportunities for several residents. Discussions were limited to code status, and documentation was lacking, as confirmed by interviews with staff.
The facility failed to conduct and document care plan meetings for several residents, including those with cognitive impairments and dementia. Residents and their representatives were not invited to participate in these meetings, and the social worker admitted to not maintaining proper documentation. The administrator was unaware of these lapses, leading to a deficiency in care planning.
A resident's controlled medication was misappropriated in an LTC facility. The resident, who was on a scheduled pain medication regime, had a card of 30 doses of oxycodone/acetaminophen go missing. The incident involved several staff members, including a new nurse and a central supply clerk, with discrepancies noted in the controlled substance count. Despite the missing medication, the resident did not miss any doses, and the facility reported the incident to authorities.
A resident with dementia and Parkinson's disease, who was fully dependent on staff for personal care, was found with long, jagged fingernails. Despite receiving regular bed baths, the resident's nails were not trimmed as needed. Staff interviews confirmed the oversight, and both the DON and Administrator acknowledged the nails should have been cut promptly.
Expired Antacid Liquid was found on a medication cart in the facility. The Unit Manager, responsible for weekly checks, missed the expired medication during her last inspection. Both the DON and Administrator confirmed that expired medications should not be available for use.
Inaccurate MDS Coding for Medications and Pneumococcal Vaccination
Penalty
Summary
The deficiency involves inaccurate coding of the Minimum Data Set (MDS) assessments for multiple residents in the areas of medications and pneumococcal vaccination status. For one resident, physician orders and the Medication Administration Record (MAR) showed Novolog insulin injections were administered on multiple days within the assessment look-back period, but the quarterly MDS was coded as receiving injections and insulin injections on only 5 of 7 days instead of 7 of 7 days; the MDS nurse later acknowledged this was an error. Another resident had an order for Dulaglutide, a non-insulin injectable medication for Type 2 diabetes, administered once during the look-back period, with no insulin orders in place, yet the quarterly MDS was coded to show both an injection and an insulin injection on 1 of 7 days; the MDS nurse stated she coded it as insulin because it was prescribed for diabetes. A third resident had no physician orders or MAR documentation for anticoagulant medications during the January and February look-back periods, but the annual MDS was coded to indicate anticoagulant use; the responsible MDS nurse stated this was an error and confirmed the resident had not received anticoagulants during the assessment period. For another resident, the quarterly MDS indicated pneumococcal vaccination was up to date, while the medical record showed only a single historical dose of PPSV23 (Pneumovax) from 2014 with no documentation of additional pneumococcal vaccines. The MDS nurse later stated that coding the vaccine status as up to date was incorrect and that she had relied on outdated CDC guidelines when completing that assessment. The DON and the Administrator both stated that resident MDS assessments should be coded accurately.
Insulin Administered Outside Ordered Blood Sugar Parameters
Penalty
Summary
The facility failed to ensure insulin was administered according to physician-ordered blood sugar (BS) parameters for a resident with diabetes mellitus type 2. The resident had an active order for Novolog insulin 10 units subcutaneously with meals, with instructions to hold the dose if BS was less than 150. Review of the December 2025 MAR showed that on four separate mornings, the nurse documented BS readings below 150 (122 on three dates and 106 on one date) and still administered 10 units of Novolog insulin at approximately 6:30 AM each time. Subsequent BS readings later those days were also documented, including elevated values and one instance where the resident refused a later BS check. During a telephone interview, the nurse stated she did not recall any parameters for the resident’s Novolog insulin and believed that if parameters existed, they would appear on the electronic MAR. She confirmed that her documentation indicated she administered 10 units of Novolog on the identified dates and times. The resident’s MDS showed he was cognitively intact, had no behaviors or rejection of care, and received insulin injections on most days in the look-back period. The NP reported familiarity with the resident, noting he frequently refused BS checks and insulin and that his BS tended to run high, but acknowledged that insulin should be given according to ordered parameters. The DON stated that administering insulin outside the physician’s parameters was considered a serious medication error, and the Administrator stated nurses should adhere to physician parameters when administering insulin.
Failure to Ensure Timely Delivery and Privacy of Resident Mail
Penalty
Summary
The facility failed to ensure residents’ right to timely access to their mail, including delivery on Saturdays and on the date it was received. During a Resident Council meeting, multiple residents reported that regular mail was not delivered as the facility received it, and that Saturday mail was not delivered until Monday or later. The Resident Council President stated that regular mail was delivered to the receptionist Monday through Friday, then sorted and passed to the activities department, but delivery to residents was inconsistent. He reported that his trade and outdoor sporting magazines and product catalogues had remained in the activities room for about a week before he collected them himself, and that these delays did not coincide with times when he was out of the facility or hospitalized. Another resident confirmed reading the President’s outdoor sporting magazines in the activities room before informing him they were there. Another resident reported visiting the activities room daily after lunch and observing that the rack holding sorted resident mail was often full, with the same items, such as the President’s magazines, remaining there for about a week before disappearing. She stated there was no set pattern for when mail was removed from the activities room, but it was obvious to her that some items sat there for multiple days before being delivered or picked up. The receptionist stated she retrieved and sorted mail Monday through Friday, placing residents’ mail in a box in the activities room, and that Saturday mail was placed in her box and typically sorted on Monday, at which time it was then placed in the activities room for delivery. The Activities Director stated that when she worked Saturdays, mail was sorted and delivered, and that activities staff present daily were expected to sort and deliver Saturday mail; however, she acknowledged that items such as bills might be held for the receptionist until Monday. The Administrator stated his expectation was that mail was delivered daily, including Saturdays, and that he was unaware of delays or resident concerns, as no grievances had been filed about timely mail delivery.
Failure to Document and Educate on Advance Directives
Penalty
Summary
The facility failed to ensure that a copy of a resident's advanced directive was included in the medical record and did not provide written advance directive information or an opportunity to formulate an advance directive for several residents. Specifically, Resident #10, who was admitted with a diagnosis of respiratory failure, did not have her Power of Attorney (POA) document included in her medical record. Despite being aware of the existence of the POA, the Admissions Director did not request a copy from the resident or her family. The Administrator noted that the Business Office Manager, who typically handled such requests, was on leave, which contributed to the oversight. Additionally, Residents #18, #51, and #84 did not receive education or an opportunity to formulate an advance directive upon admission. Their medical records lacked documentation of any discussion beyond code status. Interviews with the Admissions Director and Social Worker #1 revealed that discussions were limited to code status, and there was no documentation of the residents' understanding or decisions regarding advance directives. The Administrator confirmed that only the Do Not Resuscitate (DNR) form and physician order verification were included in the residents' charts.
Failure to Conduct and Document Care Plan Meetings
Penalty
Summary
The facility failed to conduct care plan meetings or invite residents to their care plan meetings for four residents. Resident #39, who was admitted with Alzheimer's disease and aphasia, had not had a care plan meeting since 2018, despite the requirement for quarterly meetings. The resident's representative was not invited to any care plan meetings since admission, and the social worker acknowledged the oversight. The administrator was unaware of the lapse in care plan meetings for this resident. Resident #100, who was moderately cognitively impaired, did not recall being invited to a care plan meeting since admission. The social worker responsible for arranging these meetings admitted to not inviting the resident or documenting any meetings. The Director of Nursing confirmed the absence of documentation for care plan meetings for this resident. Similarly, Resident #40, who was cognitively intact, was not invited to any care plan meetings, and there was no documentation of such meetings since admission. The social worker again admitted to not inviting the resident or maintaining documentation. Resident #117, with diagnoses including vascular dementia and diabetes, had care plan meetings documented, but the resident was not invited due to the social worker's assessment of her cognitive status. The resident expressed a desire to be involved in her care planning. The assistant administrator explained the process of inviting residents based on their cognitive status, but the administrator expected all residents to be invited to care plan meetings. The facility's failure to invite residents and their representatives to care plan meetings and maintain proper documentation led to the deficiency.
Misappropriation of Controlled Medication
Penalty
Summary
The facility failed to protect a resident's right to be free from the misappropriation of controlled medication. Resident #40, who was cognitively intact and on a scheduled pain medication regime for chronic pain, was prescribed oxycodone/acetaminophen to be administered four times daily. A discrepancy was discovered when a card of 30 doses of this medication and the corresponding controlled substance count record sheet went missing from the medication cart. The incident involved several staff members, including nurses and a central supply clerk. On 7/3/24, Nurse #3, who was new to the facility, completed a controlled substance reconciliation count with Nurse #4, but a discrepancy in the number of controlled medication cards was noted. Despite this, Nurse #3 signed off on the count. Later, Central Supply Clerk #1 was given keys to the medication room by Nurse #3, which was against protocol, and Nurse #4 later took the keys from the clerk. The missing medication was discovered the following day during a shift change count by Nurse #2 and Nurse #4. Interviews with staff revealed inconsistencies in the handling and reconciliation of controlled substances. Nurse #4, who had a previous reprimand on her nursing license related to narcotic medications, was implicated in the incident, although it could not be proven. The facility's administrator confirmed the missing medication and reported the incident to relevant authorities, including the NCBON and law enforcement.
Failure to Provide Adequate Nail Care for Dependent Resident
Penalty
Summary
The facility failed to provide adequate nail care for a dependent resident, identified as Resident #18, who was unable to perform activities of daily living independently. Resident #18, who was readmitted to the facility with diagnoses including dementia, Parkinson's disease, and early onset cerebellar ataxia, was observed to have approximately half-inch long fingernails with jagged edges on both thumbs. Despite being totally dependent on staff for bathing and grooming, the resident's nails were not trimmed as needed, which was confirmed during an observation and interview with the resident on 11/12/24. Nurse Aide (NA) #1, who was responsible for providing bed baths to Resident #18, stated that she had cleaned the resident's nails but did not believe they required trimming. However, upon further observation and interview, NA #1 acknowledged the need to cut the resident's nails. Nurse #1 and the Director of Nursing (DON) both confirmed that the nails should have been trimmed due to their jagged condition. The facility's Administrator also acknowledged that the nails should have been cut in a timely manner if needed.
Expired Medication Found on Medication Cart
Penalty
Summary
The facility failed to discard expired medication that was available for use on one of the medication carts. During an observation of the Upper 300 Hall medication cart, an opened bottle of Antacid Liquid with an expiration date of July 2024 was found. The Unit Manager, who was responsible for checking the medication cart weekly for expired medications, acknowledged that the medication was expired and should not have been available for use. She admitted to having missed this bottle during her last check on November 11 or 12, 2024. The Director of Nursing confirmed that the Unit Manager was responsible for monitoring the carts weekly to ensure expired medications were discarded, and the Administrator also stated that expired medications should not be on the carts.
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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