Brunswick Health & Rehab Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Ash, North Carolina.
- Location
- 9600 No 5 School Road, Ash, North Carolina 28420
- CMS Provider Number
- 345575
- Inspections on file
- 26
- Latest survey
- April 9, 2026
- Citations (last 12 mo.)
- 7
Citation history
Health deficiencies cited at Brunswick Health & Rehab Center during CMS and state inspections, most recent first.
A resident with dementia, osteoporosis, and prior femur fracture experienced an unwitnessed fall and subsequently developed severe hip pain and decreased ability to ambulate and transfer. Nursing staff failed to document the fall on the day it occurred, did not complete comprehensive lower‑extremity or mobility assessments, and repeatedly charted pain scores of 0 despite the resident’s complaints and nurse aide reports of significant pain with movement and increased assistance needs. An NP evaluated the resident for hip pain but was not informed of the fall, did not assess the hips or legs, and treated the pain as baseline neuropathic discomfort. Over several days, PRN acetaminophen was given intermittently without consistent pain scoring, multiple shifts lacked progress notes or assessments, and aides assumed nurses were aware of the resident’s worsening pain and functional decline. Bilateral hip x‑rays were eventually ordered after internal communication about hip pain, and the report later showed an acute displaced femoral neck fracture, after which the resident was sent to the hospital and underwent a left hip hemiarthroplasty.
A resident with dementia, osteoporosis, and a prior femur fracture experienced an unwitnessed fall followed by new, severe hip pain and loss of mobility. Over several days, multiple nurses and NAs observed screaming, crying, grimacing, and difficulty with transfers and ambulation, yet documentation was inconsistent, pain scores of 0 were repeatedly recorded, PRN acetaminophen was used minimally, and no thorough pain or lower extremity assessments were documented. The NP evaluated the resident for hip pain without being informed of the fall, did not assess the lower extremities, attributed the pain to nerve pain, and instructed staff to give PRN acetaminophen and educate the cognitively impaired resident to request pain medication. Aides continued to note pain with movement but sometimes did not report it, assuming nurses were aware. Days later, a supervisor documented hip discomfort and ordered mobile x‑rays, which revealed an acute displaced femoral neck fracture, after which the resident was sent to the hospital and underwent a left hip hemiarthroplasty.
A resident with end stage renal disease and other serious conditions was found with an opened bottle of naproxen and multiple opened tubes of prescription lidocaine-prilocaine cream at the bedside, which the resident reported self-administering for headaches and prior to dialysis. The resident had no assessment for self-administration, no related physician orders, and no care plan addressing self-administration, and the assigned medication aide, unit manager, and DON were unaware that the resident possessed or was using these medications. The physician stated that these medications should not be self-administered without supervision and that residents must be assessed for safe self-administration, but this process had not been completed for the resident, and the medications were stored unsecured in the room.
A resident with CVA, hemiplegia, hemiparesis, and expressive aphasia, care-planned for slide board and two-person assistance for wheelchair-to-bed transfers, was instead lifted by the back of her pants by a CNA without using the slide board or a second staff member. The resident’s pants were ripped, she became upset and cried, and she later reported feeling unsafe during the transfer due to inability to use her right arm and leg. A cognitively intact roommate witnessed the event, confirmed that the CNA hoisted the resident by her pants without assistance, and stated the CNA declined an offered gait belt. Nursing documentation and staff interviews corroborated that the prescribed transfer method and required assistance were not followed, and the resident told the NP that the CNA had been rough, though no physical injury was found.
A resident with ESRD on hemodialysis, hyperkalemia, and heart failure had physician orders and RD documentation for a renal diet with double protein portions at each meal and a 1000 mL/24-hour fluid restriction, with specific meal-by-meal fluid allocations. Observations showed the resident repeatedly received meal trays that exceeded the ordered fluid limits and did not provide double protein portions, including a lunch tray with 600 mL of fluids and non-renal-appropriate items such as potatoes and tomato-based ravioli, and a breakfast with only one egg instead of a double protein portion. The resident reported that staff frequently served foods inconsistent with his renal diet and were unaware of his fluid restriction, and a large cup of orange juice was observed at his bedside. Dietary and nursing staff interviews revealed lack of understanding of renal diet requirements, failure to use posted renal restriction lists, and absence of a system to ensure trays matched diet and fluid orders, while leadership acknowledged expectations that such orders be followed.
A cognitively intact resident with end stage renal disease, GI hemorrhage, and anemia had ordered medications including Velphoro, sucralfate, and midodrine, but surveyors observed four medication cups containing these drugs left unattended on the bedside table while the assigned medication aide was at the cart and unable to see the resident. The aide confirmed the medications belonged to the resident, stated they must have been left from a prior shift, and acknowledged she had not yet given that morning’s doses and that staff are expected to observe residents swallowing medications. A nurse from the previous shift also denied intentionally leaving medications at the bedside but agreed this practice was inappropriate. The resident reported that nurses often left medications at the bedside without always informing him he was expected to take them. The physician stated that failure to receive these medications as ordered had the potential for significant adverse effects, and both the unit manager and DON stated that medications were not to be left at the bedside and that residents must be assessed before any self-administration is allowed.
A resident with documented allergies to tea and tomatoes, including prior mouth and throat swelling from tomatoes, was served a meal containing tomato sauce because the tomato allergy was not included on the care plan interventions or the dietary tray ticket, even though it appeared in the clinical record. At lunch, the resident received beef ravioli with tomato sauce on a renal diet tray that only listed a tea allergy, and reported having been served tomatoes and tomato sauce on previous occasions despite informing staff. The Medical Records Manager, a NA, and the Dietary Manager all stated they were unaware of the tomato allergy and relied on tray tickets or electronic transfers of allergy data, which only reflected the tea allergy, while the DON stated she expected nursing-entered allergies to be communicated to dietary and honored.
A resident in an LTC facility exhibited symptoms of C. difficile infection, including loose stools with a foul odor and abdominal discomfort. Despite reports from staff and the resident's responsible party, the facility failed to assess and treat the condition appropriately. The resident's condition worsened, leading to septic shock and death after being transferred to the hospital. The facility's inadequate response and lack of medical intervention contributed to the deficiency.
A resident with persistent symptoms of C. diff infection experienced a fatal outcome due to the NP's failure to communicate with the Medical Director. Despite the resident's worsening condition, including 42 stools in 24 days, the NP did not consult the Medical Director or order necessary tests. The resident was eventually transferred to the hospital, diagnosed with septic shock secondary to C. diff, and passed away. Interviews revealed a lack of communication protocols between the NP and Medical Director.
Two residents experienced undignified care at the facility. One resident, admitted for rehabilitation, was denied bathroom assistance and told to urinate in bed, causing distress and embarrassment. Another resident was changed while standing over a wheelchair, which was deemed rude and insensitive. The nurse aide involved had a history of loud and rough behavior, leading to disciplinary actions.
The facility failed to remove expired food items from the dry storage and nourishment rooms, affecting all residents. Expired items included breakfast syrup, corn chips, cookies, and supplemental shakes. The refrigerator for resident use was at an incorrect temperature, and the Dietary Manager acknowledged oversight in routine checks. The Administrator expected adherence to guidelines to prevent potential foodborne illnesses.
The facility failed to manage medications properly, with expired and loose pills found in medication carts and unsecured medication administration to a cognitively impaired resident. Expired loperamide HCL and loose pills were observed in medication carts, and a resident's medications were left unsecured at the bedside. Staff acknowledged these issues, indicating a lapse in adherence to medication management protocols.
A resident was transferred to the hospital without complete medical information being communicated. The nursing supervisor provided a transfer form but failed to give a full verbal report to the hospital. The resident was later diagnosed with septic shock due to Clostridium Difficile. The DON and medical director expected a complete report to be given, which was not done.
A resident with a history of falls and muscle weakness was improperly assisted by a nurse aide during incontinence care, leading to the resident being lowered to the floor. The aide, unaware of the resident's need for two-person assistance, attempted the transfer alone without a gait belt, contrary to the care plan.
A resident with a neurogenic bladder and an indwelling urinary catheter received improper care when a Wound Treatment Nurse placed the catheter drainage bag on the bed, level with the bladder, during a dressing change. Additionally, a Nurse Aide failed to use soap and did not clean the urethral meatus or entire catheter tubing as per protocol. These actions were contrary to the facility's care plan and could lead to infection risks.
Two residents experienced significant medication errors in an LTC facility. One resident received another's medications due to a nurse's orientation error, leading to temporary vital sign changes. Another resident missed three doses of an antianxiety medication due to a shortage, risking withdrawal symptoms. Staff interviews highlighted procedural lapses and communication issues.
A resident with a history of stroke and left side weakness did not receive a prescribed hand splint due to a lack of communication and documentation in the facility. The occupational therapist ordered and created a splint, but it was not included in the care plan or medication administration record, leading to nursing staff being unaware of its necessity. The splint was found in the resident's closet, missing a Velcro band, and staff interviews revealed a lack of awareness and training regarding the splint's application.
A resident with an anxiety disorder missed three doses of Lorazepam due to the facility's failure to maintain adequate stock in the automated medication dispenser. Despite a physician's order, the medication was unavailable, and alternative options were not pursued. The usual process for ordering refills was disrupted, leading to the deficiency.
A facility failed to follow its infection control policy for Enhanced Barrier Precautions (EBP) when a Wound Nurse provided care to a resident with chronic wounds without wearing a gown. The resident, who had multiple open wounds, was initially placed on EBP but was later put on contact precautions due to a COVID-19 outbreak. After the contact precautions ended, the facility did not reinstate EBP, leading to a deficiency in infection control practices.
Failure to Assess and Respond to Post‑Fall Hip Pain and Mobility Decline
Penalty
Summary
The deficiency involves the facility’s failure to comprehensively assess, recognize, and respond to a resident’s severe hip pain and functional decline following a reported unwitnessed fall. The resident had dementia, osteoporosis, and a history of femur fracture, and was previously able to transfer and ambulate with limited assistance. On the date of the unwitnessed fall, there was no nursing progress note, no documentation of a fall, no pain complaint, and no assessment of the lower extremities or of transfers, ambulation, or mobility. Nursing documentation on that date reflected a pain score of 0, and the nurse assigned to the resident did not recall any fall, pain, or assessment. The quarterly MDS showed severe cognitive impairment and a prior fall, but no pain assessment. On the following night, a nurse documented that the resident was having “a lot of pain” in her hip and placed a note in the doctor’s book, but did not call the on‑call provider, did not document administration of any pain medication, and did not record a pain score with the complaint. The nurse aide on that shift did not recall changes, but the nurse later reported that the aide had told her the resident was unable to ambulate, which was a change from baseline. The next day, another nurse documented in a late entry that the resident reported she had fallen the previous day, pulled herself up, and had not told anyone, and that the resident screamed in pain when moved. This nurse contacted the NP, who, according to the note, stated the resident complained of pain all the time; the nurse informed him that this pain was not typical. The progress note did not include a pain level, a lower extremity assessment, or documentation that the unwitnessed fall was communicated to the NP. The NP’s own note documented nonspecific hip pain, a sleepy and groggy presentation, and neuropathic/hip pain, but did not include an assessment of the legs or hips. The NP later stated he was unaware of the fall, did not assess the hips or legs, and did not inquire about changes in condition such as pain with movement or ambulation. Over the next several days, multiple nurses documented pain scores of 0 on the MAR despite intermittent administration of PRN acetaminophen and reports from nurse aides that the resident had significant pain with transfers, ambulation, and repositioning. Nurse aides reported that the resident, who had previously been able to get up and ambulate, now required increased assistance, had difficulty transferring and ambulating, and grimaced and winced in pain during movement. One aide kept the resident in bed and provided all care in bed due to pain with movement, while another aide did not report the pain to the nurse, assuming the nurse was already aware. There were no nursing progress notes on some days documenting any assessment of the lower extremities or of the resident’s ability to transfer, ambulate, or move, and some assigned nurses did not enter any assessment notes at all. A nursing supervisor received a Stop and Watch communication about hip pain, obtained an order for bilateral hip x‑rays, but did not complete a comprehensive assessment and did not document a pain level or lower extremity assessment. The x‑ray order was entered, and bilateral hip x‑rays were completed, but pain scores of 0 continued to be documented on the MAR by nursing staff, and the unit manager assigned for part of one day did not assess the resident. A nurse aide who assisted with the x‑ray reported that repositioning the resident in bed was difficult due to pain and observed grimacing and wincing. The x‑ray report later showed an acute left femoral neck fracture with displacement. The nurse who came on duty the next day found the x‑ray report on the fax machine, noted the fracture, and contacted the provider, after which the resident was sent to the emergency department. The hospital history and physical documented that the resident endorsed hip pain on arrival and was treated with analgesics and later underwent a left hip hemiarthroplasty. The NP and Medical Director both acknowledged that there was potential for complications when a fracture remained undiagnosed for several days while the resident continued to be moved, transferred, and assisted with ambulation. The DON confirmed that the facility’s investigation determined that a nurse had been informed of an unwitnessed fall and failed to report the incident, resulting in a delay in treatment, and emphasized the importance of thorough assessment and documentation.
Failure to Assess and Manage Pain After Unwitnessed Fall Leading to Delayed Fracture Diagnosis
Penalty
Summary
The deficiency involves the facility’s failure to provide safe, appropriate pain management and assessment for a severely cognitively impaired resident following an unwitnessed fall and subsequent onset of significant hip pain. The resident had a history of right femur fracture, osteoporosis, and dementia, and was admitted with an order for PRN acetaminophen 650 mg for unspecified pain. Prior to the incident, the resident required limited assistance with transfers, bed mobility, and toileting, used a wheelchair, and only occasionally had pain that rarely interfered with activities. On the date of the unwitnessed fall, there was no nursing progress note, no documentation of a fall, no assessment of the left lower extremity, and no assessment of changes in transfer, ambulation, or mobility, despite the nurse on duty documenting a pain level of 0. The nurse later stated he did not assess the resident for pain or range of motion and acknowledged the resident was cognitively impaired and had an impaired ability to request pain medication. Over the following days, multiple staff observed or were informed of the resident’s significant pain and changes in mobility, but assessments, documentation, communication, and pain management remained inadequate. During the night after the fall, another nurse documented that the resident was having “a lot of pain in her hip” and placed a note in the doctor’s book, but did not document a pain or head-to-toe assessment, did not administer PRN acetaminophen, and nevertheless recorded a pain score of 0 on the MAR. Nurse aides reported that the resident was screaming, crying, yelling out with transfers, unable to ambulate as before, and required care in bed due to pain with movement. One nurse documented, as a late entry, that the resident reported she had fallen the previous day and was screaming in pain when moved; this nurse contacted the NP, who stated the resident complained of pain all the time and instructed staff to give PRN acetaminophen and indicated he would evaluate the resident the next day. The late entry note did not document a pain level, a lower extremity assessment, or that the unwitnessed fall was communicated to the NP. The MAR showed PRN acetaminophen was given once and marked only as “slightly effective,” with no numerical pain monitoring, while pain scores of 0 continued to be documented on subsequent shifts despite ongoing pain behaviors. When the NP evaluated the resident, the chief complaint was hip pain, and nursing staff had reported that the resident was having pain. The NP documented that the resident was oriented to person only, had dementia and anxiety, appeared sleepy and groggy, and had non‑specific pain. The NP’s assessment did not include an examination of the lower extremities, and the plan was to treat presumed nerve and hip pain with PRN acetaminophen and to educate the resident to request pain medication, despite her severe cognitive impairment and inability to reliably rate or request pain. The NP later stated he was unaware of the fall and that, had he known, he would have ordered x‑rays immediately, and acknowledged that new onset severe pain should prompt imaging. Over the next several days, aides continued to observe the resident’s pain with transfers, ambulation, and repositioning, including wincing, grimacing, holding her hip, and needing increased assistance, but some aides did not report these findings to nurses, assuming the nurses were already aware. Nursing documentation remained sparse, with no progress notes on some days, inconsistent pain scores, limited use of PRN analgesics, and no thorough pain or mobility assessments recorded. Eventually, a nursing supervisor documented that the resident appeared to be in discomfort and verbalized hip pain, and mobile x‑rays were ordered. The progress note did not include a pain level or a detailed assessment of the left lower extremity. The x‑ray, completed days after the onset of severe pain, showed an acute displaced left femoral neck fracture. The following day, a nurse documented the x‑ray results and arranged for the resident’s transfer to the emergency department. At the hospital, the resident reported hip pain and was treated with IV hydromorphone, cyclobenzaprine, and acetaminophen, and underwent a left hip hemiarthroplasty without complications before returning to the facility. Throughout the period from the unwitnessed fall to the diagnosis of the fracture, the facility failed to ensure timely and thorough pain assessment, accurate pain documentation, effective communication of the fall and subsequent changes in condition to the NP and physician, and appropriate pain management for a resident who was unable to verbalize or request pain medication due to severe cognitive impairment. The DON stated that her expectation was that residents with pain would be thoroughly assessed regardless of cognitive status, that staff would monitor for pain and report increased pain or changes in condition to the physician, and that this resident was unable to rate or request pain and should have been assessed using non‑verbal indicators and provided pain medication as needed.
Failure to Assess and Authorize Resident Self-Administration of Medications
Penalty
Summary
The facility failed to determine whether self-administration of medications was clinically appropriate for a cognitively intact resident on dialysis who was reviewed for self-administration of drugs. The resident had diagnoses including renal dialysis, end stage renal disease, gastrointestinal hemorrhage, and anemia, and the quarterly MDS showed the resident was cognitively intact with no behaviors. Despite this, the resident was not care planned for self-administration of medications, and there was no assessment in the electronic medical record regarding the resident’s ability to self-administer medications. The physician’s orders did not include naproxen sodium or lidocaine-prilocaine cream, nor did they include any order authorizing the resident to self-administer medications. Surveyor observation found an opened bottle of naproxen sodium 500 mg and four opened tubes of prescription lidocaine-prilocaine cream on the resident’s overbed tray table while the assigned medication aide was outside the room at the medication cart and unaware that these medications were present. The resident reported that he kept naproxen in his room to take for headaches and that he applied the lidocaine cream to his fistula prior to dialysis, stating that his responsible party had brought these medications from an outside pharmacy. The physician stated that the resident should not self-administer naproxen or lidocaine cream without supervision and that residents were to be assessed for safe self-administration. The unit manager and DON both confirmed that residents must be assessed for self-administration, require a physician’s order specifying which medications may be self-administered, must have medications stored properly, and must have the care plan updated, and both stated they were unaware that this resident was self-administering and keeping these medications unsecured in the room.
Failure to Follow Care-Planned Transfer Method and Use Required Assistance
Penalty
Summary
The deficiency involves the facility’s failure to transfer a resident according to the care plan, specifically by not using a slide board and required assistance during a wheelchair-to-bed transfer. The resident had been admitted with a recent CVA, right-sided hemiplegia, hemiparesis, and expressive aphasia, and her care plan identified her as at risk for falls with an ADL functional deficit related to limited transfer ability. The care plan interventions required use of a slide board for transfers from wheelchair to bed, and the MDS documented that she had moderately impaired cognition and required substantial assistance for transfers. On the night in question, a nurse aide transferred the resident from her wheelchair to her bed without following the prescribed method. According to the resident and her cognitively intact roommate, the aide lifted or hoisted the resident by the back of her pants instead of using the slide board and a second person, resulting in the resident’s pants being ripped. The resident reported that the aide did not transfer her correctly, that she needed a slide board and two-person assistance, and that she felt upset, cried, and did not feel safe during the transfer because she could not use her right arm or right leg. The roommate stated she witnessed the transfer, saw the aide hoist the resident by her pants without assistance, and noted that the aide declined an offer to use the roommate’s gait belt. Staff accounts and documentation further described the events leading to the deficiency. A nurse progress note recorded that the roommate approached the nurse supervisor at the start of shift with concerns about the resident’s mood and the way the aide had transferred her, and the resident confirmed that the aide had pulled her up by her pants, ripping them. The nurse supervisor’s written statement indicated that when she arrived on the unit, the roommate reported concerns that the aide had needed assistance and should have used a gait belt, and that the aide responded argumentatively, stating she did the best she could because they were short staffed. The supervisor later found both residents upset and was told that the aide had returned to the room and told the roommate to come to her directly if she had a problem. The nurse practitioner’s note documented that the resident stated the aide was rough with her, although no physical injuries were found on exam. The assistant director of nursing and another aide reported that the aide did not request assistance with the transfer during the shift.
Failure to Follow Renal Diet and Fluid Restriction Orders for Dialysis Resident
Penalty
Summary
The deficiency involves the facility’s failure to follow physician orders for a resident on hemodialysis who required a renal diet with double protein portions and a 1000 mL/24-hour fluid restriction. The resident had end stage renal disease, renal dialysis, hyperkalemia, and heart failure, and was care planned for increased nutrition and hydration risk related to these conditions, including a therapeutic renal diet and fluid restriction. The physician’s order and RD note specified a renal diet with double protein at every meal and a 1000 mL fluid restriction, with 600 mL to be provided by Dietary (240 mL at breakfast, 240 mL at lunch, 120 mL at dinner) and 400 mL by Nursing (200 mL on first shift and 200 mL on second shift). The care plan interventions included maintaining the fluid restriction as ordered and encouraging compliance with the prescribed diet. During a lunch observation, the resident’s tray ticket correctly listed a renal diet, a 1000 mL/day fluid restriction with a 240 mL limit at lunch, and double protein portions, but the actual tray contained items inconsistent with these orders. The tray included a small serving of beef ravioli with tomato sauce, potatoes and carrots, a dinner roll, strawberry ice cream, 8 ounces of water, and 8 ounces of ginger ale, totaling 600 mL of fluid at that meal alone, exceeding the 240 mL lunch allowance. Double portions of protein were not provided. The Medical Records Manager, who is a nurse aide assisting with meal delivery, did not recognize that the tray exceeded the fluid restriction or that the protein portion was not doubled, and she stated she was not sure what a renal diet consisted of. The resident reported that the facility did not follow his renal diet, that he was often served inappropriate foods such as potatoes and processed lunch meats, and that staff were not aware of his fluid restriction. An additional observation of the resident’s bedside table showed a large 12-ounce cup of orange juice that he stated had been provided with breakfast despite his fluid restriction. Interviews with dietary staff further demonstrated failures in implementing the ordered renal diet and fluid restriction. The Dietary Manager acknowledged that the small serving of ravioli did not meet the double protein requirement, that potatoes should not have been served due to the renal diet restriction, and that the tray ticket listing 8 ounces of water, 8 ounces of a beverage of choice, and 4 ounces of sherbet exceeded the resident’s 240 mL fluid limit at lunch. She also stated there was no system in place to ensure residents consistently received the correct diet or appropriate tray items. A dietary staff member who prepared the lunch tray stated she relied on the tray card and did not check the posted renal diet restriction list. A subsequent breakfast observation showed the resident received one fried egg and one slice of toast with 4 ounces of coffee, which the RD confirmed did not meet the ordered double protein portion, noting that a double portion would be 3–4 eggs. The DON stated she expected fluid and diet restrictions to be followed as ordered, with Dietary responsible for preparing trays per orders and Nursing responsible for reviewing tray tickets and being knowledgeable about special diets such as renal diets.
Medications Left Unattended at Bedside and Not Administered as Prescribed
Penalty
Summary
The deficiency involves the facility’s failure to ensure that prescribed medications were properly administered and not left unattended at a resident’s bedside. A cognitively intact resident with diagnoses including renal dialysis, end stage renal disease, gastrointestinal hemorrhage, and anemia had multiple medications ordered: Velphoro 500 mg three times daily for hypokalemia at 7:00 AM, 11:00 AM, and 4:00 PM; sucralfate 1 gram four times daily, to be given 30 minutes before meals and at bedtime; and midodrine 10 mg once daily and 5 mg twice daily, to be held if systolic blood pressure exceeded 130 mmHg. During observation, four plastic medication cups containing a large round brown tablet (Velphoro), a white oblong tablet (sucralfate), and a small white pill (midodrine) were found on the resident’s bedside table while the Medication Aide assigned to the cart was outside the room and could not see the resident. The Medication Aide confirmed the medications belonged to the resident and stated they must have been left from a prior shift’s medication pass, acknowledging she had not yet administered that morning’s medications and had not been in the room. She reported being assigned to the resident on the prior day’s 7:00 AM–3:00 PM shift but did not recall leaving medications at the bedside, and stated that medications should never be left at the bedside and residents should be observed swallowing them. A nurse assigned to the resident on the 3:00 PM–11:00 PM shift the same day also did not recall leaving medications at the bedside but agreed it was not appropriate to leave medications unattended and unsecured. The resident reported that nurses often left medications at the bedside for self-administration and did not always inform him that the medications were there or that he was expected to take them. The physician stated that the resident not receiving Velphoro, sucralfate, and midodrine as prescribed had the potential to result in significant adverse effects, and the Unit Manager and DON both stated that medications were not to be left at the bedside and that staff were expected to remain with residents to observe medication ingestion unless the resident had been assessed and approved for self-administration, which had not occurred in this case.
Failure to Honor Documented Food Allergy in Meal Service
Penalty
Summary
The deficiency involves the facility’s failure to provide food that accommodated a documented tomato allergy for one resident. The resident’s care plan, initiated on 8/19/25, listed food allergies to tea and tomatoes, and subsequent hospital discharge documentation and a cardiology progress note confirmed allergies including anaphylaxis to tea and mouth and throat swelling in response to tomatoes. The resident’s electronic health record and clinical dashboard also listed food allergies to tea and tomatoes, and a nutritional status problem dated 3/30/26 noted a tea allergy with an intervention to ensure allergen avoidance, but did not include the tomato allergy in the care plan. On 4/7/26 at lunchtime, the resident received a meal tray that included beef ravioli with tomato sauce, despite the documented tomato allergy. The tray ticket listed a renal diet, tea allergy, fluid restriction, and double protein portions, but did not list a tomato allergy. The actual meal observed on the tray included beef ravioli with tomato sauce, potatoes and carrots, a dinner roll, strawberry ice cream, water, and ginger ale. The resident informed the Medical Records Director, who was delivering the tray, that he was allergic to tomatoes and requested an alternate meal, stating he could not eat processed deli meat and chose an egg salad sandwich instead. Interviews revealed that the resident reported being served tomatoes and tomato sauce previously and had told staff delivering trays that he could not eat tomatoes. The Medical Records Manager, who also worked as a nurse aide when delivering trays, stated she checked tray tickets for allergies and diets and was unaware of the tomato allergy because it was not on the tray ticket. A nurse aide familiar with the resident also stated she was not aware of a tomato allergy and relied on tray tickets for allergy information. The Dietary Manager reported she was unaware of the tomato allergy, explained that nursing entered allergies into the clinical record and that she was responsible for ensuring allergies appeared in the meal tray ticket system, and noted that tea was listed as an allergy in her system but tomatoes were not. The DON stated she expected food allergies to be communicated from nursing to dietary and honored, and that allergies were supposed to transfer from the clinical dashboard to the Dietary Manager’s system and be included on the diet order slip provided to dietary.
Failure to Diagnose and Treat C. difficile Infection
Penalty
Summary
The facility failed to assess, diagnose, and medically treat a resident who exhibited signs of Clostridium Difficile (C. difficile) infection. The resident presented with symptoms such as loose stools with a foul odor, abdominal discomfort, tiredness, loss of appetite, and inability to get out of bed. Despite these symptoms, the facility did not recognize the seriousness of the condition and failed to implement effective interventions. The resident's condition deteriorated, leading to decreased urine output, which was not identified as a medical emergency by the facility. The resident's medical records showed a pattern of frequent loose stools, yet there was no care plan or interventions related to bowel incontinence or loose stools. Nursing staff and therapists reported the resident's condition to the Nurse Practitioner (NP), but no significant action was taken. The NP ordered banana flakes and later loperamide, which is contraindicated in C. difficile cases, but did not order any diagnostic tests for C. difficile. The resident's responsible party also expressed concerns about the resident's condition, but these were not adequately addressed by the facility. The resident was eventually transferred to the hospital at their request, where they were diagnosed with septic shock secondary to C. difficile and passed away. The facility's failure to properly assess and treat the resident's symptoms, as well as the lack of communication and follow-up on reported issues, contributed to the deficiency. The report highlights the facility's inadequate response to the resident's deteriorating condition and the lack of appropriate medical intervention.
Failure to Communicate Resident's Condition Leads to Fatal Outcome
Penalty
Summary
The deficiency involved a Nurse Practitioner (NP) who failed to communicate and collaborate with the Medical Director regarding a resident's persistent symptoms indicative of Clostridium Difficile (C. diff) infection. The resident, who had been admitted with a subdural hematoma, experienced 42 stools in 24 days, many of which were loose and foul-smelling. Despite these symptoms, the NP did not consult with the Medical Director or order a stool sample for analysis, even after the resident's Responsible Party (RP) reached out to a Gastroenterologist for advice. The NP's progress notes consistently documented the resident's loose stools but did not indicate any communication with the Medical Director. The NP prescribed banana flakes and later loperamide to manage the symptoms but did not assess the effectiveness of these treatments or consult with the Medical Director. The resident's condition worsened, leading to a high panic level white blood cell count, which was not communicated to the Medical Director. Eventually, the resident requested to be transferred to the hospital, where he was diagnosed with septic shock secondary to C. diff and subsequently passed away. Interviews with facility staff revealed a lack of a system for communication between the NP and the Medical Director regarding significant changes in residents' conditions. The Medical Director was not informed of the resident's critical lab values or the severity of his symptoms. The Director of Nursing (DON) was also unaware of the communication protocols between the NP and the Medical Director, assuming that changes were reported as needed. This lack of communication and oversight contributed to the resident's deteriorating condition and eventual death.
Removal Plan
- The Medical Director will review the provider notes for all residents with a change in condition that were seen by any of the Nurse Practitioners and/or Physician Assistants. Any new orders or suggestions made by the Medical Director will be communicated to the Nurse Practitioner/Physician Assistant and the Director of Nursing for follow-up.
- The Medical Director educated all Providers working with the facility on the clostridium difficile protocol. The protocol indicates that residents with three or more watery or loose stool in a 24 hour time span should have a medication review to ensure laxatives are not contributing to the loose stool. If the loose stool does not resolve within 24 hours of the laxatives being stopped or the resident was not receiving laxatives, a clostridium difficile test will be performed. The NP was included in the provider education.
- The Director of Nursing was educated by the Regional Director of Clinical Services on providing the Medical Director with a list of residents that were seen by a Nurse Practitioner and/or Physician Assistant in the previous seven days, due to a change in condition, weekly for the Medical Director to review.
- The Director of Nursing will review all progress notes weekly to determine the residents that were seen in the past 7 days for a change in condition.
- The Medical Director will review the Nurse Practitioner and/or Physician Assistant progress notes weekly and communicate any suggestions to the Nurse Practitioners and/or Physician Assistants and the facility.
- The Regional Director of Clinical Services communicated the new review process to the provider groups Nurse Practitioners and/or Physician Assistants.
- The Medical Director was informed of the new review process by the Director of Nursing and is in agreement with the system of communication and collaboration.
Failure to Maintain Resident Dignity in Care
Penalty
Summary
The facility failed to uphold residents' rights to dignity and self-determination, as evidenced by two separate incidents involving inappropriate care by a nurse aide. In the first incident, a resident admitted for rehabilitation following acute respiratory failure and with a history of hypertensive heart disease and chronic kidney disease, was denied assistance to the bathroom by Nurse Aide #9. Despite being cognitively intact and capable of using a walker, the resident was told to urinate in bed, leading to feelings of embarrassment and distress. The nurse aide's actions were contrary to the facility's policy, which did not require therapy evaluation before ambulation, and the resident's request for assistance was ignored, resulting in a loss of dignity. In the second incident, another resident, who was cognitively intact and required assistance with activities of daily living, was subjected to undignified incontinence care. The resident was changed while standing over a wheelchair, holding onto a walker, rather than being assisted to a bed or bathroom. This method of care was deemed rude and insensitive by the resident, who expressed discomfort with the practice. The nurse aide involved admitted to using this method previously with other residents, indicating a pattern of behavior that compromised resident dignity. Interviews with facility staff, including the Director of Nursing and the Assistant Director of Nursing, confirmed that the actions of Nurse Aide #9 were inappropriate and not in line with the facility's standards for providing dignified care. The nurse aide's approach to care, characterized by loud and rough behavior, had previously resulted in disciplinary actions, highlighting ongoing issues with maintaining resident dignity and respect within the facility.
Expired Food Items and Improper Storage Temperature Found
Penalty
Summary
The facility failed to manage food storage and expiration effectively, as observed during a survey. In the dry storage room, several expired food items were found, including twelve bottles of sugar-free breakfast syrup, multiple bags of corn chips, a case of chocolate chip cookies, and fruit punch powder mix with no expiration date. The Dietary Manager admitted to not knowing how long the fruit punch powder had been stored and acknowledged that the expired items were overlooked despite a weekly stock rotation process. This oversight was attributed to a failure in the routine checks meant to prevent expired items from remaining in storage. Additionally, in one of the two nourishment rooms, the refrigerator designated for resident use was found to be at an incorrect temperature of 22 degrees Fahrenheit, and it contained expired supplemental shakes. The Dietary Manager indicated that the Dietary Aide was responsible for monitoring refrigerator temperatures and removing expired products, but the expired items were not removed despite being logged as checked. The Administrator expressed an expectation that dietary staff should adhere to guidelines for discarding expired food to prevent potential foodborne illnesses among residents.
Medication Management Deficiencies in LTC Facility
Penalty
Summary
The facility failed to adhere to proper medication management protocols, as evidenced by the presence of expired medications and loose pills in medication carts. During an observation of Medication Cart #4, expired doses of loperamide HCL were found, along with loose white pill halves. Nurse #7 acknowledged the presence of these expired and loose medications, stating it was the nurse's responsibility to check for expired medications. Similarly, Medication Cart #2 was found to contain 12 loose pills of various colors, shapes, and sizes. Nurse #8 admitted that loose pills should not be present and suggested that pills might pop out of blister packs during handling. The Director of Nursing confirmed that expired medications should not be on the carts and that it was the responsibility of the nursing staff to maintain the carts. Additionally, the facility failed to ensure the secure administration of medications to a severely cognitively impaired resident. During an observation, a medication cup with three pills was found on the bedside table of a resident diagnosed with atrial fibrillation, COPD, and hypertension. The resident indicated that the nurse had brought the medications earlier. Nursing Supervisor #2 admitted to leaving the room before ensuring the resident had taken all the medications, which included Xarelto, Losartan, and Prednisone. The Director of Nursing stated that nurses should ensure residents take all medications before leaving the room.
Incomplete Medical Information Transfer to Hospital
Penalty
Summary
The facility failed to communicate complete medical information for a resident transferred to the hospital. The resident, who was admitted to the facility, requested to be sent to the hospital due to decreased urination and inability to eat. The nursing supervisor completed a transfer form indicating the resident's vital signs and reason for transfer but did not provide a complete verbal report to the hospital. The resident was later diagnosed with septic shock secondary to Clostridium Difficile upon arrival at the hospital, with critically high white blood cell count and other severe symptoms. Interviews revealed that the nursing supervisor attempted to call the hospital to provide a verbal report but was disconnected and did not attempt to call back due to other duties. The resident's responsible party and the medical director expected a complete report to be given to the hospital, which was not done. The Director of Nursing also expected nurses to provide a full report to the hospital, which was not fulfilled in this case.
Inadequate Supervision During Incontinence Care
Penalty
Summary
The facility failed to provide adequate supervision and care during incontinence care for a resident, resulting in the resident being lowered to the floor. The resident, who was admitted with a history of muscle weakness and falls, required two-person assistance for all transfers as per his care plan. However, on the day of the incident, a nurse aide attempted to provide incontinence care alone, without the assistance of another staff member, and without using a gait belt. The resident was stood up using a walker, and during the process of sitting him back down, he lost balance and was lowered to the floor. The nurse aide involved in the incident had not worked with the resident for over a month and was unaware of the current transfer requirements. She believed the resident's condition had improved and attempted to manage the transfer alone. The care plan, which indicated the need for two-person assistance, was not followed, leading to the incident. The resident did not sustain any injuries from the fall, but the failure to adhere to the care plan and provide necessary assistance during transfers was a significant oversight.
Improper Catheter Care and Positioning
Penalty
Summary
The facility failed to maintain proper care for a resident with an indwelling urinary catheter, leading to potential risks of infection. During a sacral pressure ulcer dressing change, the Wound Treatment Nurse placed the resident's catheter drainage bag on the bed, level with the resident's bladder, instead of keeping it below the bladder. This action was contrary to the care plan, which required the drainage bag to be positioned below the bladder to prevent backflow of urine and potential infection. The resident, who was cognitively intact and dependent on staff for mobility and activities of daily living, had a neurogenic bladder and an unstageable pressure ulcer. Additionally, the facility failed to provide appropriate catheter care. During an observation, a Nurse Aide did not use soap while cleaning the catheter and did not clean the urethral meatus or the entire catheter tubing as per the facility's protocol. The Nurse Aide started cleaning below the catheter insertion site and did not pull back the urethral meatus to clean around the penis, which is necessary to prevent contamination and infection. The Nurse Aide acknowledged the deviation from the training she had received. Interviews with the Director of Nursing and the Medical Director confirmed that the catheter care provided was not in line with the facility's protocol and expectations. Both the Wound Treatment Nurse and the Nurse Aide did not adhere to the established procedures, which are critical in preventing infections in residents with indwelling urinary catheters.
Medication Errors and Shortages in LTC Facility
Penalty
Summary
The facility failed to prevent significant medication errors for two residents. In the first case, a nurse in orientation administered medications intended for another resident to a severely cognitively impaired resident. The medications included several antihypertensives, which were not prescribed for the resident, leading to a temporary decrease in heart rate and blood pressure. The error occurred when the orienting nurse was left to administer medications unsupervised, resulting in the wrong medications being given to the wrong resident. In the second case, a resident with anxiety disorder missed three doses of a prescribed antianxiety medication due to the facility running out of the medication. The nursing staff failed to ensure the medication was reordered in a timely manner, and alternative medications available in the automated dispensing machine were not considered. The resident was at risk for withdrawal symptoms, although no adverse effects were documented. Interviews with staff revealed communication and procedural lapses, such as the failure to monitor the resident for withdrawal symptoms and the lack of timely medication reordering. The facility's automated medication dispensing machine inventory log showed discrepancies in medication availability, contributing to the missed doses. The medical director expressed concern over the recurring issue of medication shortages at the facility.
Failure to Communicate Therapy Order for Hand Splint
Penalty
Summary
The facility failed to effectively communicate a therapy order for a left hand splint to the nursing staff for a resident with a contracture and limited range of motion. The resident, who had a history of stroke with left side weakness, was supposed to receive a splint to prevent further contracture of the left hand. Despite the occupational therapist's (OT) efforts to order and create a splint, there was a lack of follow-through in ensuring the splint was applied and maintained as part of the resident's care plan. The occupational therapist initially assessed the resident and determined the need for a splint, but the splint was delayed due to being on back order. A temporary splint was made by the OT, but there was no clear communication or documentation in the resident's care plan or medication administration record regarding the application and maintenance of the splint. Nursing staff were not adequately informed or trained on the use of the splint, leading to its absence in the resident's care routine. Interviews with various staff members revealed a lack of awareness and understanding of the resident's need for the splint. The splint was eventually found in the resident's closet, but it was missing a Velcro band necessary for its application. The interim Therapy Rehab Director and the Director of Nursing acknowledged the oversight in communication and documentation, which resulted in the resident not receiving the necessary care to maintain range of motion and prevent further contracture.
Failure to Administer Antianxiety Medication Due to Stock Shortage
Penalty
Summary
The facility failed to ensure that an antianxiety medication, Lorazepam, was available for administration as ordered by the physician, resulting in three missed doses for a resident diagnosed with an anxiety disorder. The resident was admitted with a physician's order for Lorazepam 0.5 mg to be administered three times a day. On a specific day, the resident missed all three scheduled doses because the medication was not available in the facility's automated medication dispensing machine, which was supposed to have a stock of 8 tablets but was recorded as having none. Nurse #4, who was on duty, did not administer the medication due to the shortage and documented the missed doses in the medication administration record. The nurse had been informed by Nurse #6, who worked the previous shift, that the medication was out and that an escript was needed. Despite notifying the pharmacy, the medication was not delivered until late that evening, resulting in the missed doses. The facility's usual process for ordering controlled medications was disrupted as the Evening Supervisor Nurse, responsible for checking medication needs, was out sick, leaving the responsibility to the floor nurses, who failed to ensure the medication was reordered in time. Interviews with various staff, including the Psychiatric Physician Assistant and the Director of Nursing, revealed that alternative medications were available in the automated dispenser, but the staff did not notify the provider to consider these options. The Pharmacy Manager confirmed that the medication was sent out for delivery late, and the Director of Nursing emphasized the expectation for nursing staff to reorder medications before they run out. The Medical Director expressed concern over the recurring issue of medication shortages at the facility.
Failure to Implement Enhanced Barrier Precautions During Wound Care
Penalty
Summary
The facility failed to implement its infection control policy and procedures for Enhanced Barrier Precautions (EBP) during wound care for a resident with chronic wounds. The Wound Nurse was observed providing care to a resident with multiple open wounds on the lower extremities and toes without wearing a gown, although gloves were used. The facility's policy required EBP, including the use of gowns and gloves, for high-contact care activities involving residents with chronic wounds to prevent the transmission of multi-drug resistant organisms. However, the Wound Nurse mistakenly believed that EBP was only necessary for residents with chronic wounds, not realizing that it also applied to the care activities she was performing. The Infection Control Preventionist Nurse acknowledged that the resident was initially placed on EBP upon admission due to chronic wounds but was later placed on contact precautions due to a COVID-19 outbreak. After the resident was removed from contact precautions, the facility failed to reinstate EBP. The Director of Nursing confirmed that staff had been trained on EBP and should have used a gown and gloves during wound care. The oversight in continuing EBP after the resident's contact precautions ended led to the deficiency in infection control practices.
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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