Brunswick Rehabilitation And Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Bolivia, North Carolina.
- Location
- 1070 Old Ocean Highway, Bolivia, North Carolina 28422
- CMS Provider Number
- 345549
- Inspections on file
- 25
- Latest survey
- May 5, 2026
- Citations (last 12 mo.)
- 9
Citation history
Health deficiencies cited at Brunswick Rehabilitation And Healthcare Center during CMS and state inspections, most recent first.
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.
The deficiency centers on multiple failures in controlled substance management, including diversion, tampering, and administration of discontinued narcotics. Discontinued Lorazepam, Oxycodone, and Hydrocodone/Acetaminophen remained in controlled substance boxes on med carts instead of being promptly returned to the pharmacy, leading to inaccurate narcotic counts and missing tablets. Several blister packs of Oxycodone and Hydrocodone/Acetaminophen were found taped or perforated, with tablets replaced by Metoprolol, Seroquel, Hydroxyzine, or lower-dose opioids, while declining count sheets and return logs documented that some pills "did not match." A nurse admitted administering Lorazepam and Oxycodone to residents without checking the eMAR, removing doses after the physician orders had been discontinued and without corresponding MAR entries. Staff interviews described discovering taped blister packs and non-matching pills during shift-change narcotic counts, and the DON and regional clinical leadership identified that discontinued controlled substances were not being removed from the carts and returned as required, allowing misappropriation and use of medications without active orders.
Staff failed to maintain resident dignity during wheelchair transport and assisted feeding. A resident with dementia and severe cognitive impairment was transported in a geriatric wheelchair while facing backward, slumped over, and moaning as a CNA pulled the chair from the front, preventing the resident from seeing where he was going. Two cognitively impaired, fully dependent residents were assisted with eating by CNAs who stood over them rather than sitting at eye level, despite chairs being available in the room and dining area. One CNA reported not knowing she was expected to sit while feeding, and another stated she remained standing to monitor other residents who were self-feeding while she was the only staff member present.
A resident with peripheral vascular disease and a left above-knee amputation, who was moderately cognitively impaired and receiving PRN opioid analgesia for pain, had a Hydrocodone/Acetaminophen order changed from 10 mg/325 mg to 5 mg/325 mg every 6 hours PRN. The MAR for the month showed both the discontinued 10 mg/325 mg order and the new 5 mg/325 mg order, and review of the controlled substance declining count sheets revealed that nurses repeatedly removed 10 mg/325 mg tablets while documenting administration of 5 mg/325 mg on the MAR, and on two occasions removed 10 mg/325 mg tablets with no corresponding MAR entry. The NP confirmed the resident should have been receiving only the 5 mg/325 mg dose during this period, and the DON stated the discontinued 10 mg/325 mg supply and count sheet should have been removed when the order was changed.
A resident with traumatic brain injury, diabetes, moderately impaired cognition, and an ADL self-care deficit requiring total assistance with eating was left waiting for feeding assistance after a breakfast tray was placed within view at the bedside. An agency CNA with 16 residents, including two needing feeding assistance, reported being too busy and unfamiliar with residents to assist promptly, despite trays having been delivered earlier. Continuous observation showed no staff entering the room to help the resident eat for an extended period, while the assigned nurse, who knew two residents required feeding assistance, remained at the nurses’ station and stated she was unaware the resident had not been fed and had not been asked for help. Feeding assistance was only initiated after this delay.
A resident with ESRD on hemodialysis, CHF, COPD, and chronic respiratory failure had physician orders for daily, later weekly, weights to monitor CHF, but staff repeatedly failed to obtain weights as ordered and did not document reasons for missed weights or refusals. Over multiple weeks, weight records showed large, unexplained fluctuations, including gains of 20–25 lbs and a same-day difference of nearly 60 lbs, without same-day reweighs or documented verification of accuracy. Nursing staff and CNAs obtained and recorded weights on posted lists, but significant discrepancies were entered into the record without review of prior values, and the Unit Manager and DON were not notified of these changes, despite the resident’s need for accurate weight monitoring.
A resident with hypertension, CHF, and CAD had repeated episodes of markedly elevated BP that met parameters for PRN Clonidine, yet nursing staff did not administer the medication or document any clinical rationale for withholding it. The same resident also received Isosorbide Mononitrate despite ordered hold parameters requiring the drug to be withheld when systolic BP was below a specified threshold, with no justification documented. Nursing staff interviews revealed lack of awareness of the PRN order and the hold parameters, while the resident, with moderately impaired cognition, reported being on BP medications and experiencing headaches and dizziness at times.
The facility failed to accurately document PRN opioid pain medication administration on the MAR for four residents, despite corresponding removals recorded on controlled substance declining count sheets. On multiple occasions, an RN removed Oxycodone or Hydrocodone/Acetaminophen for pain from the controlled drug supply but did not chart the administrations on the MAR. In an interview, the RN reported relying on her own system, administering medications without checking the order and then failing to return to sign the MAR due to being busy and forgetting. The prior DON and current DON both stated they expect nursing staff to document pain medications on the MAR, and the NP reported she depends on MAR entries to evaluate residents’ responses to PRN pain treatment.
Staff failed to follow the facility’s Contact Precautions policy while cleaning the room of a resident on precautions for suspected Norovirus and Rotavirus. Policy required staff to don gloves and a gown upon entry to rooms on Contact Precautions, with signage and PPE supplies posted at the door. On two separate occasions, housekeeping staff entered the resident’s room to clean surfaces, the bathroom, and handle trash while wearing gloves but no gown, then removed gloves and performed hand hygiene upon exit. One aide reported not noticing the precaution sign despite seeing PPE on the door, and another was unsure what Contact Precautions meant, even though leadership stated that staff had been trained to read precaution signs and use appropriate PPE before entering such rooms.
The facility failed to maintain a safe and homelike environment, with issues such as a black greenish substance around commode bases, non-functioning overhead lights, and inadequate hot water temperatures in shower rooms. These deficiencies were observed across multiple hallways, indicating a widespread problem in maintaining the facility's infrastructure.
The facility failed to provide scheduled showers for three residents with cognitive impairments and did not perform timely incontinence care for a resident with urinary issues. Staff reported being too busy to complete these tasks, leading to unmet care needs.
A resident with muscle wasting, dysphagia, and dementia did not receive the recommended Arginaid supplement for wound healing due to a breakdown in communication and process within the facility. The Registered Dietician's recommendation was not processed, leading to the resident's worsening pressure wounds. Interviews revealed that the necessary steps to implement dietary recommendations were not followed, resulting in a significant lapse in care.
The facility did not notify the physician or nurse practitioner when a resident's blood pressure medication was repeatedly withheld or when another resident received a blood pressure-increasing medication outside of prescribed parameters. These actions were not communicated as required, though no significant outcomes were reported for the two residents involved.
The facility did not provide the required 8 hours of RN coverage on multiple days, as confirmed by staffing records and PBJ data. Despite recruitment efforts and use of agency staff, the facility was unable to consistently meet RN staffing requirements.
A consultant pharmacist did not identify or address that a resident's Carvedilol, prescribed for hypertension, was held 17 times in one month without physician-ordered parameters. The medication was withheld by nursing staff based on blood pressure readings, but the pharmacist's monthly review did not note or recommend action regarding this irregularity, and the physician was unaware of the frequent holds.
Nursing staff failed to follow physician orders for two residents, resulting in significant medication errors. One resident's antihypertensive medication was repeatedly withheld without physician notification or documentation, despite no hold parameters being ordered. Another resident received an antihypotensive medication outside of prescribed blood pressure parameters on multiple occasions, with no documentation or provider notification. Clinical leadership and the consultant pharmacist were unaware of these errors until after they occurred, and staff interviews confirmed the deviations from proper medication administration.
Surveyors found that food items in the kitchen's walk-in refrigerator, reach-in refrigerator, and dry goods pantry were not properly labeled, dated, or discarded when expired. Multiple items, including juices, fruit, hot dogs, and pantry goods, were observed without required dates or past expiration. Staff interviews confirmed that facility protocols for food safety were not followed, leading to the storage of expired and unlabeled food.
The facility repeatedly failed to sustain compliance in several areas, including monitoring hot water temperatures in shower rooms, providing incontinence care to dependent residents, maintaining required RN coverage, accurately documenting daily nursing hours, and ensuring proper labeling and discarding of food items. These deficiencies persisted due to ineffective monitoring and evaluation of corrective action plans under the QAPI program.
Staff failed to follow Enhanced Barrier Precautions by not wearing required gloves and gowns during high-contact care for residents with chronic wounds and invasive devices. A nurse provided wound care without PPE, and two nurse aides performed incontinence care for a resident with a pressure ulcer and feeding tube using gloves only, despite clear facility policy and signage.
A facility failed to protect a resident from neglect when a nurse did not perform daily wound care for an infected Stage IV pressure ulcer on the left heel and an unstageable wound on the right heel, both acquired in the facility. This deficiency was identified through observations, record reviews, and staff interviews, indicating a failure to follow the physician's orders for wound care.
A facility failed to provide sufficient nursing staff, resulting in delayed incontinence care for a resident. The resident, who required assistance due to impairments, was left in a saturated brief for an extended period. Despite ringing the call bell, timely care was not provided due to the overwhelming workload of the nurse aide responsible. The facility had only six nurse aides for 81 residents, leading to inadequate care provision.
A resident requiring extensive assistance and using a mechanical lift was not provided with their preferred two showers per week, receiving only one bath in a month despite no refusals. Staff cited the difficulty of providing showers as the reason, and the DON confirmed the resident should have received two showers weekly per preference, but this was not scheduled or provided.
A resident with advanced dementia, diabetes, and peripheral arterial disease did not receive daily wound care for bilateral heel ulcers as ordered by the physician. Documentation and staff interviews confirmed that wound dressings were not changed for over 48 hours, resulting in soiled and dislodged dressings, despite clear care plans and physician orders for daily treatment. The lapse was attributed to missed handoff, lack of documentation in the electronic record, and staff being too busy to complete the care.
Surveyors observed that the facility did not maintain a medication error rate below 5%, with three errors out of 25 opportunities. In one case, a nurse administered a blood pressure medication without checking the resident's blood pressure as required by the physician's order. In another case, a medication aide initially omitted two prescribed medications for a resident, only realizing the mistake after being questioned and correcting it before administration.
A resident with bilateral contractures, a feeding tube, and a history of malnutrition did not receive a timely occupational therapy evaluation as ordered by a provider. Staff were unaware of the OT order, and the process for communicating therapy referrals was inconsistently followed, resulting in the resident struggling to eat independently and not receiving needed adaptive equipment or assistance as outlined in the care plan.
The facility did not accurately document or post daily nurse staffing information on multiple occasions, including leaving reports blank, omitting shift data, and incorrectly recording RN coverage when none was present. These issues were confirmed through record review and staff interviews.
The facility failed to provide 8 hours of RN coverage on 28 of 45 days reviewed due to staff resignations and changes in employment status. Despite efforts to recruit new RNs, significant gaps in coverage, particularly on weekends, were not adequately addressed.
The facility failed to ensure refrigerated meat items stored in the walk-in refrigerator for resident sandwiches were dated and sealed. Two clear plastic bags of sliced sandwich ham were found not sealed or dated and were open to air. The Dietary Manager (DM) acknowledged that the items should have been dated and sealed, and the Administrator confirmed the expectation for kitchen staff to follow all regulatory guidelines for food and kitchen sanitation safety.
The facility's QAA program failed to maintain procedures and monitor interventions, resulting in repeat deficiencies in nurse staffing information, medication administration, and medical record documentation. Issues included inaccurate daily nursing hours postings, failure to follow physician orders for insulin and Zoloft, and incorrect documentation in the eMAR.
The facility failed to accurately document the administration of as-needed narcotic pain medications in the eMAR for two residents. Nurses admitted to either forgetting to sign off the medications or being unable to unlock the eMAR for documentation. The Unit Manager and Administrator confirmed the expectation for accurate documentation in both the narcotic record and the eMAR.
The facility inaccurately documented Daily Nursing Hours postings, reporting RN coverage on two dates when no RN was present. This discrepancy was confirmed through record reviews and staff interviews.
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.
Controlled Substance Diversion, Tampering, and Use of Discontinued Narcotics
Penalty
Summary
The deficiency involves the facility’s failure to maintain effective safeguards and systems to prevent diversion and misuse of controlled substances, and to ensure discontinued controlled medications were promptly removed from use and accurately tracked. For multiple residents, discontinued narcotics and other controlled medications remained in the controlled substance boxes on medication carts for extended periods after the physician orders had been discontinued. Declining count sheets and return logs showed that large quantities of Lorazepam, Oxycodone, and Hydrocodone/Acetaminophen remained on the carts and were not returned to the pharmacy at the time of discontinuation, resulting in inaccurate narcotic counts. Surveyors identified specific instances of tampering and drug substitution in blister packs for several residents. For one resident, a discontinued Lorazepam 0.5 mg order left 90 tablets on the cart; the declining count sheet later showed 83 tablets remaining, but only 82 were actually returned to the pharmacy, with one tablet missing. For another resident with an Oxycodone 5 mg prescription, the declining count sheet and subsequent investigation revealed that three Oxycodone tablets had been removed and replaced with Metoprolol tablets, while the count sheet initially still reflected 90 tablets until the discrepancy was corrected to 87 Oxycodone tablets returned. For a resident prescribed Hydrocodone/Acetaminophen 10/325 mg, the blister pack was found to have one tablet replaced with a lower-dose Hydrocodone/Acetaminophen 5/325 mg, and only 42 of the original 60 tablets were returned. Additional residents’ Oxycodone blister packs were also found to be tampered with and to contain substituted medications. One resident with a short-term Oxycodone 5 mg order had a blister pack where six tablets did not match; investigation determined that three tablets had been replaced with Seroquel, two with Metoprolol, and one with Hydroxyzine, and only 12 Oxycodone tablets were ultimately returned. Another resident with a brief Oxycodone 5 mg order had one tablet replaced with Metoprolol, with eight Oxycodone tablets returned. Multiple nurses reported seeing narcotic blister packs on the carts that were taped on the back or had small breaks in the foil, and some packs contained pills that did not match the ordered narcotic. One nurse acknowledged that she sometimes taped blister packs back up when pills popped out, and several staff described discovering taped blister packs and pills that did not match the expected appearance of Oxycodone. The facility also failed to prevent administration of discontinued controlled medications. For one resident whose Lorazepam 0.5 mg order had been discontinued, the declining count sheet showed tablets being removed on several dates months later by two nurses, despite there being no active physician order and no corresponding entries on the Medication Administration Records. One of these nurses stated that her “system was not good,” that she administered medications based on what she believed residents received without checking the electronic MAR, and that whenever she removed Lorazepam for this resident, she administered it. For another resident whose Oxycodone 5 mg order had been discontinued, the declining count sheet showed doses removed on later dates by the same nurse, again without an active order and without MAR documentation. The DON and Regional Clinical Director repeatedly identified the core system failure as the lack of timely removal and return of discontinued controlled substances from the medication carts, which allowed misappropriation, tampering, and administration of medications without active physician orders. Throughout these events, documentation and verification processes for controlled substances were inconsistent or incomplete. Some pharmacy delivery receipts were unsigned, some declining count sheets lacked nurse signatures for doses removed, and notes on the count sheets documented that certain pills “did not match” the ordered medication. Staff interviews confirmed that taped blister packs and non-matching pills were observed during shift-change narcotic counts, and that concerns were not always immediately escalated. The cumulative findings showed that the facility’s systems for controlled substance storage, counting, discontinuation handling, and verification were ineffective, resulting in inaccurate narcotic counts, missing tablets, tampered blister packs, and removal and administration of controlled medications without active physician orders.
Failure to Maintain Resident Dignity During Transport and Assisted Feeding
Penalty
Summary
The deficiency involves failure to honor residents’ rights to dignity and respectful treatment during transport and meals. One resident with dementia, anxiety, severe cognitive impairment, and total dependence for ADLs was observed seated in a geriatric wheelchair, slumped over with his head hanging and eyes open, and moaning while a nurse aide pulled the chair down the hall from the front, causing the resident to face backward and be unable to see where he was going. The aide reported she pulled the chair because it was hard to push and acknowledged she had been educated on dignity and respect and should have pushed the resident in front of her, which would have allowed her to see his slumped posture and hear his moaning. The DON confirmed that the resident should have been pushed in front of the aide and that this was a dignity issue. The deficiency also includes failure to promote dignity during meals for two residents with severely impaired cognition who were dependent on staff for eating. One resident with a traumatic brain injury was observed in bed with the head of the bed elevated while an agency nurse aide stood over the bedside and assisted with eating without sitting at eye level, despite a chair being available in the room; the aide stated she had never heard of needing to sit to feed a resident and only sat after being questioned. The other cognitively impaired, fully dependent resident in a semi-reclined geriatric chair in the dining room was fed by the same nurse aide, who stood over the resident while feeding despite an empty chair being available; the aide later stated she believed she had no chair and also needed to stand to watch three other residents feeding themselves at another table while she was the only staff member present in the dining area. The DON stated she expected staff to sit when assisting residents during meals to promote dignity.
Wrong Opioid Dose Administered After Order Change
Penalty
Summary
The deficiency involves the facility’s failure to follow a physician’s order for an opioid pain medication, resulting in administration of the wrong dose multiple times. The resident involved had peripheral vascular disease and a left above-knee amputation and was moderately cognitively impaired, receiving PRN opioid medication for pain rated 6/10. A physician’s order for Hydrocodone/Acetaminophen 10 mg/325 mg every 6 hours as needed was discontinued and replaced with an order for Hydrocodone/Acetaminophen 5 mg/325 mg every 6 hours as needed. The November Medication Administration Record (MAR) showed both the discontinued 10 mg/325 mg order (effective until mid-month) and the new 5 mg/325 mg order starting mid-month. There was no documentation that the 10 mg/325 mg dose was administered during the first part of the month. After the dose change, documentation discrepancies showed that nursing staff removed the discontinued 10 mg/325 mg tablets from the controlled substance declining count while documenting administration of the 5 mg/325 mg dose on the MAR. On several occasions, nurses documented giving 5 mg/325 mg on the MAR while the declining count sheets showed removal of 10 mg/325 mg tablets, and on two occasions 10 mg/325 mg tablets were removed from the narcotic count with no corresponding MAR entry. Attempts to interview the involved nurses were unsuccessful. The Nurse Practitioner confirmed that during the relevant period the resident’s order was for 5 mg/325 mg and that the nurses removed 10 mg/325 mg tablets instead, resulting in the resident receiving the wrong dose. The DON stated that the discontinued 10 mg/325 mg declining count sheet and blister pack should have been removed from the medication cart when the order was discontinued.
Failure to Timely Assist Dependent Resident With Feeding
Penalty
Summary
The deficiency involves the facility’s failure to provide necessary assistance with eating to a cognitively impaired resident who was totally dependent on staff for feeding. The resident had diagnoses including traumatic brain injury and diabetes, with a care plan noting an ADL self-care deficit related to failure to thrive, lack of coordination, and muscle weakness, and interventions specifying assistance with ADLs including eating. A comprehensive MDS assessment documented moderately impaired cognition and total dependence on staff for feeding, and the resident was also receiving Hospice services. On the morning in question, the resident was observed seated upright in bed with a breakfast tray placed on the bedside table within view. The agency nurse aide assigned to the resident reported having 16 residents on her assignment, including two who required feeding assistance, and stated she had been busy assisting other residents and had not yet had time to assist this resident with eating, even though the breakfast trays had been delivered approximately 25 minutes earlier. Continuous observation from 9:20 AM to 9:45 AM showed no staff entering the resident’s room to assist with the meal. The assigned nurse for the hall, who acknowledged that there were two residents needing assistance with eating, was observed sitting at the nurses’ station and stated she was unaware the resident had not been fed and that the nurse aide had not asked her for help. The resident ultimately began receiving feeding assistance at 9:50 AM, after a delay of about 45 minutes from tray delivery.
Failure to Obtain and Verify Ordered Weights for a Medically Complex Resident
Penalty
Summary
The deficiency involves the facility’s failure to obtain and document resident weights as ordered by the physician and to verify the accuracy of significant weight changes for a resident with complex medical conditions. The resident was admitted with end stage renal disease requiring hemodialysis and congestive heart failure (CHF), and had a physician’s order dated 1/29/26 for daily weights for CHF. In February, multiple days had no recorded weights, and there was no documentation in the progress notes from 2/1/26 through 2/21/26 explaining the missed weights or indicating any refusals by the resident. After a hospitalization in late February through 3/4/26, the resident’s care plan dated 3/9/26 identified risk for nutritional compromise and weight fluctuations due to end stage renal disease, hemodialysis, COPD, and chronic respiratory failure, and included an intervention to obtain weights per physician order. In March, weights were scheduled daily at 6:00 AM, but several days again had no recorded weights and no progress note explanations for the omissions. Documented weights showed large, unexplained fluctuations, including a jump from 197 lbs to 222 lbs on 3/9/26 and a 25 lb gain to 245 lbs on 3/24/26, followed the same day by a 57.8 lb lower weight of 187.2 lbs. There was no documentation that any of these significant changes were reweighed the same day, nor that the Unit Manager or DON were notified of the discrepancies. Following another hospitalization from 3/25/26 through 4/2/26 for shortness of breath with coughing and wheezing, a new physician’s order dated 4/2/26 directed weekly weights for CHF. In April, weights were recorded on several dates, including a 10 lb increase from 183.3 lbs on 4/20/26 to 193.2 lbs on 4/21/26, with no progress note documentation that a reweigh was completed or that the accuracy of this change was verified. No further weights were recorded after 4/21/26 despite the weekly weight order. Interviews with staff and the NP confirmed that weights were to be obtained per orders, that significant changes should be rechecked the same day, and that accurate weights were particularly important for this resident, but also revealed that the Unit Manager was not aware of the missed daily weights or significant discrepancies, and that one nurse entered a reweigh without reviewing the prior documented weight.
Failure to Follow Antihypertensive and Vasodilator Medication Parameters
Penalty
Summary
The deficiency involves the facility’s failure to follow physician orders for antihypertensive and vasodilator medications for a resident with hypertension, congestive heart failure, and coronary artery disease. The resident had an order dated 12/13/25 for Clonidine 0.2 mg every 12 hours as needed for systolic blood pressure greater than 180 or diastolic blood pressure greater than 90. The Medication Administration Records (MARs) for December 2025 and January 2026 showed multiple instances of significantly elevated blood pressures, including readings such as 248/100, 210/87, 235/101, 231/90, 187/88, and 212/87, documented by nursing staff. Despite these readings meeting the ordered parameters for as-needed Clonidine, there was no documentation that Clonidine was administered on those dates, nor was there any documented clinical rationale for withholding the medication in the nursing progress notes. Interviews with nursing staff revealed a lack of awareness and follow-through regarding the as-needed Clonidine order. One nurse stated she had not been assigned to the resident for a while prior to recording the elevated blood pressures, and another nurse reported she was not aware that the resident had an order for as-needed Clonidine for elevated blood pressure. When later contacted, that nurse declined to comment further on the medication issue that occurred in January. The Nurse Practitioner confirmed that the as-needed Clonidine was ordered for a reason and that the blood pressure parameters should have been followed, with the medication administered when indicated. The facility also failed to follow hold parameters for Isosorbide Mononitrate extended release 60 mg, ordered on 4/6/26 to be given once daily for angina with instructions to hold the medication if systolic blood pressure was less than 120. The April 2026 MAR showed that the medication was administered on multiple occasions when the resident’s systolic blood pressure was below 120, including readings of 112/76, 118/70, and 118/75, with no documentation or clinical justification in the nursing progress notes for giving the medication despite the hold parameters. A nurse involved stated she had not held the Isosorbide Mononitrate and did not realize the medication had hold parameters, explaining that the hold parameters were not noticeable on the electronic MAR and were therefore overlooked. The resident, who had moderately impaired cognition per a quarterly MDS, reported being on blood pressure medications but did not know which ones or their schedule, and described experiencing headaches and dizziness at times. The Nurse Practitioner and the DON both stated that ordered parameters for these medications should have been followed by the nursing staff.
Failure to Accurately Document PRN Controlled Substances on MAR
Penalty
Summary
The deficiency involves the facility’s failure to accurately document the administration of controlled substances on the Medication Administration Record (MAR) for four residents, despite corresponding entries on the controlled substance declining count sheets. For one resident with an order for PRN Oxycodone 5 mg every 8 hours, Nurse #1 repeatedly documented removal of tablets on the declining count sheet on multiple dates and times, but did not document administration on the MAR for those same dates and times. A second resident with an order for PRN Hydrocodone/Acetaminophen 5 mg/325 mg every 6 hours had doses removed per the declining count sheet on two occasions, yet Nurse #1 did not record those administrations on the MAR. A third resident with PRN Oxycodone 5 mg orders (first every 4 hours for up to 7 days, then every 6 hours) had doses removed on two separate days at 8:00 AM and 12:00 PM, but again, Nurse #1 failed to document these administrations on the MAR. A fourth resident with an order for PRN Oxycodone 5 mg every 6 hours for 3 days had a dose removed per the declining count sheet, but there was no corresponding documentation on the MAR for that date. In a phone interview, Nurse #1 stated that her “system was not good,” that she knew which medications residents received and would administer them without looking at the order, and that she did not sign the MAR because she was too busy and forgot to return to complete the documentation. The previous DON stated she expected nursing staff to sign off on the MAR whenever administering pain medications and emphasized the importance of MAR documentation to determine if pain was being managed. The Nurse Practitioner reported that she relies on the MAR to assess residents’ responses to PRN pain medications, and the current DON stated she expected accurate documentation of pain medication administration on the MAR and identified that the nurse did not follow the medication administration process, which includes documentation.
Failure to Follow Contact Precautions During Room Cleaning
Penalty
Summary
The facility failed to implement its infection control policy and procedures for Contact Precautions when staff cleaned the room of Resident #37, who was on Contact Precautions for suspected Norovirus and Rotavirus. The facility’s Infection Control Policy dated January 2026 required staff and visitors to wear gloves and a gown when entering the room of a resident on Contact Precautions and to remove the PPE before leaving the room. Resident #37’s room had a Contact Precautions sign posted on the door and a PPE supply bag with gloves and gowns hanging on the door. During an observation on 4/22/26, Housekeeping Aide #1 was seen in the resident’s room cleaning surfaces and handling trash while wearing gloves but no gown, and she removed her gloves and performed hand hygiene before leaving the room. During a separate observation on 4/23/26, Housekeeping Aide #2 was observed cleaning the same resident’s room, including the bathroom and trash, while also wearing gloves but no gown, and he removed his gloves and performed hand hygiene before exiting. In interviews, Housekeeping Aide #1 stated she did not see the Contact Precautions sign because the door was open, although she saw the PPE supplies, and acknowledged she should have worn a gown and gloves before entering. Housekeeping Aide #2 stated he was unsure what Contact Precautions meant, despite reporting that he had received infection control training. The Housekeeping Manager, ADON/Infection Preventionist, and DON all stated that staff had received infection control training and were instructed to read precaution signs and wear appropriate PPE when entering rooms on transmission-based precautions, and confirmed that the housekeeping aides should have worn both gloves and gowns when entering Resident #37’s room.
Deficiencies in Facility Maintenance and Resident Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment for its residents, as evidenced by several deficiencies observed during a survey. In multiple resident rooms, a black greenish substance was found around the base of the commodes, indicating a lack of proper cleaning and maintenance. Additionally, overhead lights in some rooms were non-functioning, leaving residents to rely on natural light from windows and open doors. These issues were noted across three of the five hallways observed, highlighting a widespread problem in maintaining the facility's infrastructure. Furthermore, the facility failed to maintain appropriate hot water temperatures in the shower rooms on the 300-hall. The water temperatures in the showers fluctuated significantly, with readings well below the expected 114 degrees Fahrenheit, making it unsuitable for resident use. The Maintenance Director acknowledged the issue, attributing it to the distance the hot water had to travel from the boiler and the lack of monitoring due to an incomplete electronic maintenance log. These deficiencies indicate a failure in the facility's maintenance processes and oversight, impacting the residents' right to a safe and comfortable living environment.
Failure to Provide Scheduled Showers and Timely Incontinence Care
Penalty
Summary
The facility failed to provide adequate bathing and showering assistance to residents who were dependent on staff for activities of daily living (ADL). Resident #39, who was severely cognitively impaired and dependent on staff due to Alzheimer's disease and other health conditions, did not receive her scheduled shower on the night of 2/15/25. The nurse aides on duty reported being too busy to complete the showers, and the issue was not addressed by the staff on subsequent shifts. Similar failures occurred with Resident #53 and Resident #60, both of whom also required extensive assistance due to severe cognitive impairments and did not receive their scheduled showers. Additionally, the facility failed to provide timely incontinence care for Resident #7, who was cognitively intact but dependent on staff for ADL care due to impairments and a history of urinary tract infections. On 2/16/25, Resident #7 reported that her brief had not been changed since early morning, and she was found to be wet with urine. Despite ringing her call bell for assistance, the nurse aide did not return to change her brief until hours later, resulting in a saturated brief. The nurse aide admitted to being overwhelmed with the number of residents and not adhering to the facility's protocol of checking residents every 2-3 hours. The Director of Nursing confirmed that the nurse aides on duty chose not to perform the scheduled showers, and disciplinary actions were taken. The Administrator expected the nurse aides to maintain a schedule of checking and changing residents every 2-3 hours to ensure cleanliness and skin integrity, which was not followed in these instances.
Failure to Administer Nutritional Supplement for Wound Healing
Penalty
Summary
The facility failed to provide a nutritional supplement, Arginaid, as ordered for a resident at risk for malnutrition and with significant pressure wounds. The resident, who had diagnoses including muscle wasting, dysphagia, and dementia, was recommended by the Registered Dietician to receive Arginaid twice daily for wound healing. However, the Medication Administration Record and Treatment Administration Record showed no documentation of the supplement being administered over several months. The deficiency arose from a breakdown in communication and process within the facility. The Registered Dietician made recommendations for Arginaid, which were supposed to be emailed to the Director of Nursing (DON) and then forwarded to the Unit Manager for order processing. However, the Unit Manager did not receive the recommendation, and thus, the order was never entered into the electronic medical record. This oversight was not identified until the survey period, despite the resident's ongoing need for nutritional support for wound healing. Interviews with facility staff, including the Registered Dietician, DON, and Unit Manager, revealed that the process for implementing dietary recommendations was not followed, leading to the resident not receiving the necessary supplement. The Physician confirmed that she would have signed off on the recommendation had it been presented to her. The facility's failure to administer the supplement as ordered contributed to the resident's worsening pressure wounds, highlighting a significant lapse in care coordination and communication.
Failure to Notify Physician of Medication Administration Issues
Penalty
Summary
The facility failed to notify the physician or nurse practitioner when a resident's antihypertensive medication, Carvedilol 3.125 mg, prescribed for hypertension and scheduled twice daily, was held 34 times over a 77-day period. Additionally, the facility did not inform the physician or nurse practitioner that Midodrine, a medication prescribed to increase blood pressure, was administered outside of the prescribed parameters. These deficiencies were identified through record review and interviews with staff, the nurse practitioner, and the physician. The issues involved two residents: one who did not receive the prescribed Carvedilol doses and another who received additional doses of Midodrine when their systolic blood pressure was above the specified threshold. No significant outcomes were reported for the residents involved.
Failure to Maintain Required RN Coverage
Penalty
Summary
The facility failed to provide the required 8 hours of Registered Nurse (RN) coverage on 13 specific days out of 275 days reviewed, as evidenced by both Payroll Based Journal (PBJ) staffing data and verification of daily employee timecard punches. The PBJ reports indicated no RN coverage on several dates, and the Human Resources Director confirmed that on those dates, the facility did not meet the minimum RN staffing requirement. Although there were claims that an agency RN worked on some of the dates in question, the PBJ system did not recognize these hours, and the reason for this discrepancy could not be explained by the Human Resources Director. The Administrator acknowledged ongoing difficulties in hiring RNs and reported that even the agency used to supplement staffing was unable to consistently provide licensed RNs. Despite efforts to recruit RNs through various channels such as internet advertising, social media, college skills fairs, and signage, the facility was unable to maintain the required RN coverage on the identified dates. No information about specific residents or their conditions was provided in the report.
Pharmacist Failed to Address Frequent Withholding of Antihypertensive Medication
Penalty
Summary
A deficiency occurred when the facility's consultant pharmacist failed to identify and address the frequent holding of a resident's antihypertensive medication, Carvedilol 3.125 mg, during the monthly drug regimen review. The resident, admitted with a diagnosis of hypertension, had a physician's order for Carvedilol to be administered twice daily without any parameters for holding the medication. Despite this, the medication was held 17 out of 31 days in December, as documented in the Medication Administration Record (MAR), with nurses using chart codes indicating either vital signs outside of parameters or the medication being held. There were no documented parameters or physician orders to justify these holds, and the physician was not aware of the frequency with which the medication was withheld. The monthly pharmacy review for January did not include any recommendations or notations regarding the frequent withholding of Carvedilol. During interviews, the physician confirmed she was unaware of the situation and typically did not provide hold parameters for blood pressure medications. The consultant pharmacist acknowledged that the medication should not have been held without symptoms and that the physician should have been notified after the first held dose, but stated she did not realize the extent of the holds during her review. This failure to identify and address the irregularity during the required monthly review constitutes the deficiency.
Failure to Prevent Significant Medication Errors in Two Residents
Penalty
Summary
Nursing staff failed to properly administer and document medication for two residents, resulting in significant medication errors. For one resident with hypertension, Carvedilol was prescribed to be given twice daily without any hold parameters. Despite this, nurses repeatedly held the medication when the resident's blood pressure was perceived as low, without notifying the physician or documenting the rationale in the progress notes. The medication was withheld on numerous occasions over several months, and the physician, nurse practitioner, and consultant pharmacist were not made aware of the frequency with which the medication was being held. Interviews with nursing staff revealed that they believed it was appropriate to hold the medication based on their own judgment, even though the order did not specify parameters for withholding the drug. Another resident, diagnosed with hypotension and end-stage renal disease, was prescribed Midodrine with explicit instructions to hold the medication if the systolic blood pressure exceeded 130 mmHg. Despite these clear parameters, nursing staff administered the medication multiple times when the resident's systolic blood pressure was above the specified threshold. There was no documentation explaining why the medication was given outside the prescribed parameters, nor was the physician notified of these deviations. Nursing staff acknowledged during interviews that these administrations were errors and that they were aware of the hold parameters. In both cases, the failures involved not only improper medication administration but also a lack of communication and documentation regarding deviations from physician orders. The director of nursing and other clinical leaders were unaware of the frequency and extent of these errors until they were brought to their attention during the survey. The consultant pharmacist and medical providers confirmed that they had not been notified of the medication errors until after the fact, and there was no evidence of adverse outcomes for the residents involved.
Improper Food Labeling and Storage in Kitchen and Pantry
Penalty
Summary
Surveyors observed that the facility failed to ensure proper labeling, dating, and discarding of food items in the kitchen's walk-in refrigerator, reach-in refrigerator, and dry goods storage pantry. Multiple food items, including juices, fruit, hot dogs, pudding, ground meat, and various pantry items, were found either without opened dates, without expiration dates, or past their expiration dates. These observations were made in the presence of the Dietary Manager in training, who was unable to explain why the required procedures for food labeling and discarding expired items were not followed. Interviews with the Dietary Manager in training, the Certified District Manager, and the Administrator confirmed that the facility's policy required all stored foods to be labeled, dated, and discarded when expired. However, the staff responsible for inventory and food safety did not adhere to these protocols, resulting in the storage of improperly labeled and expired food items. The deficiency was identified during the survey and had the potential to affect food served to residents.
Repeated QAPI Failures Lead to Multiple Deficiencies
Penalty
Summary
The facility failed to maintain an effective Quality Assurance and Performance Improvement (QAPI) program, resulting in repeated deficiencies across multiple areas during three federal surveys. Specifically, the facility did not sustain compliance with requirements related to maintaining appropriate hot water temperatures in resident shower rooms, providing incontinence care to dependent residents, ensuring adequate Registered Nurse (RN) coverage, accurately documenting daily nursing hours, and properly labeling and discarding food items in storage areas. These deficiencies were identified through record reviews and staff interviews, which revealed that previously developed action plans were not effectively monitored or evaluated for ongoing compliance. In the case of hot water temperature monitoring, the transition from paper logs to an electronic maintenance system led to the omission of shower rooms from the water temperature tracking form. As a result, water temperatures in these areas were not monitored, and the issue went unnoticed until the survey. For incontinence care, audits intended to ensure residents received timely assistance were discontinued after initial completion, with no further assessment to determine if the plan of correction was effective. The facility also experienced ongoing challenges in maintaining required RN coverage, with gaps in staffing persisting despite daily schedule reviews and the hiring of a weekend RN supervisor. Additional deficiencies included inaccurate documentation of daily nursing hours, as the Administrator ceased reviewing postings several months after the previous survey, resulting in blank entries. In the dietary department, the abrupt departure of the Dietary Manager led to lapses in the inspection and labeling of food items, with open and undated items found in storage areas. These repeated failures across multiple domains demonstrated the facility's inability to implement and sustain effective corrective actions through its QAPI program.
Failure to Follow Enhanced Barrier Precautions During High-Contact Resident Care
Penalty
Summary
The facility failed to implement its infection control policy and procedures for Enhanced Barrier Precautions (EBP) during direct care of residents with chronic wounds and invasive devices. Specifically, a nurse provided direct care to a resident with Stage IV and unstageable chronic foot wounds without donning the required personal protective equipment (PPE), including gloves and gown. The nurse removed soiled dressings from the resident's wounds with bare hands, despite the facility's policy requiring gloves and gown for high-contact care activities such as wound care. The nurse later acknowledged awareness of the policy and training but did not initially follow the required precautions. Additionally, two nurse aides provided incontinence care to another resident with a Stage IV pressure ulcer and a gastrostomy tube, also failing to wear gowns as required under EBP. Both aides wore gloves but did not use gowns, despite signage and PPE supplies being available outside the resident's room. Interviews revealed that the aides misunderstood the PPE requirements, believing that gloves alone were sufficient. The facility's infection control policy, updated in October 2024, clearly stated that both gloves and gowns are required for high-contact care activities for residents under EBP.
Neglect in Wound Care Management
Penalty
Summary
The facility failed to protect a resident's right to be free from neglect when a nurse did not perform the required daily wound care for an infected Stage IV pressure ulcer on the resident's left heel and an unstageable pressure wound on the right heel. Both wounds were acquired within the facility. This deficiency was identified during observations, record reviews, and staff interviews, highlighting a lapse in following the physician's orders for wound care. The incident involved one of three residents reviewed for neglect, specifically focusing on wound care management.
Inadequate Staffing Leads to Delayed Incontinence Care
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the incontinence care needs of a dependent resident, identified as Resident #7. Observations and interviews revealed that Resident #7, who was cognitively intact and required assistance with activities of daily living due to impairments, was left in a saturated brief for an extended period. The resident reported that her brief had not been changed since early morning, and despite ringing the call bell for assistance, she did not receive timely care. Nurse Aide #2, responsible for Resident #7, admitted to being overwhelmed with the number of residents assigned to her, which hindered her ability to provide timely care. The staffing assignment on the day in question showed that the facility had only six nurse aides available for 81 residents, as one of the scheduled aides was assigned to medication administration. This staffing level left each nurse aide responsible for 16 to 17 residents, which was reported by multiple staff members as insufficient to meet the residents' needs. Nurse Aide #2, who was assigned to the 100 Hall, expressed difficulty in managing her workload, which included 16 residents, and admitted to not being able to check on Resident #7 as frequently as required by the facility's protocol. Interviews with other staff members, including the scheduler and the administrator, confirmed that the facility was operating with minimal staffing levels. The administrator acknowledged the staffing situation but did not perceive it as a concern, despite staff reports of being unable to provide adequate care. The deficiency was highlighted by the failure to provide timely incontinence care to Resident #7, which was attributed to the insufficient number of nurse aides available to meet the needs of all residents effectively.
Failure to Honor Resident's Shower Preferences
Penalty
Summary
A resident with diagnoses including spondylosis, muscle weakness, venous thrombosis, and anxiety, and who required extensive to total assistance with activities of daily living, was not provided with their preferred number of showers per week. The resident, who had no cognitive impairments and required two-person assistance with a mechanical lift for transfers and showers, was scheduled for only one shower per week and received only one bath during a 30-day period. Documentation showed no evidence of shower refusals, and the resident consistently expressed a desire for two showers per week, which was not accommodated by staff. Interviews with nursing staff and the DON confirmed that the resident should have been scheduled for two showers per week and that all residents should receive showers according to their preferences. However, staff reported that it was easier to provide bed baths due to the assistance required for showers, and the resident's requests for additional showers were not fulfilled. The administrator was unaware of any complaints regarding shower frequency, and the resident's care plan and facility policy were not followed in this instance.
Failure to Provide Physician-Ordered Wound Care for Pressure Ulcers
Penalty
Summary
A deficiency occurred when a resident with multiple comorbidities, including peripheral arterial disease, diabetes, and advanced dementia, did not receive wound care for bilateral heel ulcers as ordered by the physician. The resident had a Stage IV pressure ulcer on the left heel and an unstageable deep tissue injury on the right heel, both requiring daily dressing changes with Santyl ointment and other specified dressings. The care plan and physician orders clearly indicated the need for daily wound care to prevent further decline and infection. Despite these orders, the Treatment Administration Record (TAR) showed that the wound care was not administered or documented on one of the scheduled days. Observations revealed that the resident's heel dressings were soiled, falling off, and dated two days prior, indicating that the dressings had not been changed for over 48 hours. Interviews with nursing staff confirmed that the wound care was not completed as scheduled over the weekend, with one nurse stating she was too busy and another agency nurse reporting that the task did not appear in the electronic medical record for her shift. The wound nurse and DON confirmed that the responsibility for wound care over the weekend was with the assigned nurse, and that the lapse in care was not acceptable, especially given the resident's ongoing wound infection. The wound care physician and medical director both confirmed that the resident was to receive daily wound care and that missing these treatments could impact healing and infection risk. The deficiency was identified through direct observation, record review, and staff interviews, all of which demonstrated that the facility failed to provide wound care according to physician orders for a resident with significant risk factors and ongoing infection.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, as evidenced by three medication errors observed out of 25 opportunities, resulting in a 12% error rate. During a medication pass, a nurse administered Metoprolol 25 mg to a resident without first obtaining the resident's blood pressure, despite a physician's order to hold the medication if the systolic blood pressure was less than 110 mm/Hg. The nurse later confirmed she had overlooked this requirement and had not checked the blood pressure prior to administration. In another instance, a medication aide prepared and administered medications to a resident but initially omitted two prescribed medications, Losartan 25 mg and a multivitamin, from the medication cup. The aide realized the omission only after being questioned and subsequently added the missed medications before administration. Both incidents were confirmed through staff interviews and medication reconciliation, demonstrating a failure to follow physician orders and proper medication administration procedures.
Failure to Implement Occupational Therapy Order for Resident Needing Feeding Assistance
Penalty
Summary
A deficiency occurred when the facility failed to implement a written order for an occupational therapy (OT) evaluation for a resident with a history of diabetes, protein calorie malnutrition, gastrostomy, and bilateral upper and lower extremity impairments. The resident was cognitively intact, required assistance with personal care, and was on a mechanically altered and therapeutic diet, receiving a significant portion of nutrition and fluids via a feeding tube. The care plan included monitoring for dysphagia and providing adaptive feeding equipment, but the resident was observed using regular utensils and experiencing difficulty eating independently due to hand contractures. Despite a physician's order for OT evaluation and treatment, there was no documentation that the evaluation occurred as ordered. Multiple staff interviews revealed a lack of awareness of the OT order, and the process for communicating therapy orders relied on a 'Hey Therapy' form, which was not consistently used or understood by all staff. The Rehabilitation Director and Occupational Therapist were not aware of the order, and the order was not communicated effectively between nursing and therapy departments. The resident continued to have difficulty with self-feeding, and staff were not consistently providing the necessary assistance or adaptive equipment as outlined in the care plan. Observations showed the resident struggling to eat with regular utensils and requiring assistance to consume her meal. Staff interviews indicated inconsistent understanding of the resident's needs and the process for initiating therapy services. The OT eventually evaluated the resident after the deficiency was identified, confirming the need for therapy intervention due to fatigue and limited ability to self-feed. The failure to implement the OT order and provide appropriate assistance with feeding constituted the deficiency.
Failure to Accurately Document and Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to accurately document and post daily nurse staffing information on four separate days within the review period. Specifically, the Daily Nursing Hours Report was left blank on two days, contained no data for the third shift on another day, and incorrectly documented eight hours of RN coverage on a day when no RN was present in the building. These deficiencies were confirmed through record review and staff interviews, including verification by the Human Resources Director who checked employee timecard punches and found no RN coverage on the day in question. The Administrator acknowledged the blank postings and explained that oversight of the daily postings had lapsed several months after the last recertification survey.
Failure to Provide Adequate RN Coverage
Penalty
Summary
The facility failed to provide 8 hours of Registered Nurse (RN) coverage on 28 of 45 days reviewed. The Payroll Based Journal (PBJ) Staffing Data Report for Fiscal Year - Quarter 1, 2024, and daily assignment schedules from October 1, 2023, through March 19, 2024, revealed multiple dates where RN coverage was not met. Specific dates without RN coverage included 10/08/23, 11/13/23, 11/14/23, 11/18/23, 11/29/23, 11/23/23, 12/03/23, 12/16/23, 12/20/23, 12/21/23, 12/22/23, 12/26/23, 12/30/23, 12/31/23, 01/13/24, 01/14/24, 01/27/24, 01/28/24, 02/10/24, 02/11/24, 02/14/24, 02/16/24, 02/15/24, 02/28/24, 03/04/24, 03/07/24, 03/29/24, and 03/10/24. Interviews with the facility Scheduler and the Payroll and Human Resources Coordinator confirmed the lack of RN coverage on these dates, attributing it to staff resignations and the facility's inability to use agency staffing. The facility had recently hired two RNs, one of whom had started, while the other was awaiting commencement of work. The Administrator acknowledged the deficiency, citing staff resignations and changes in employment status as contributing factors. Two RNs had switched to PRN (as needed) status, and several others had quit. Efforts to recruit new RNs included advertising on social media, distributing flyers in the community, using a state-based recruiting site, and attending job fairs. Despite these efforts, the facility experienced significant gaps in RN coverage, particularly on weekends, which were not adequately addressed by the current staffing strategies.
Improper Storage of Refrigerated Meat Items
Penalty
Summary
The facility failed to ensure refrigerated meat items stored in the walk-in refrigerator for resident sandwiches were dated and sealed. During an observation of the kitchen's walk-in refrigerator, two clear plastic bags of sliced sandwich ham were found not sealed or dated and were open to air. The Dietary Manager (DM) was unable to explain why the food was not properly stored. In an interview, the DM stated that she monitored the items in the refrigerators and freezers weekly when conducting inventory and acknowledged that the two bags of sliced ham should have been dated and sealed. The Administrator confirmed that it was his expectation for the kitchen staff to follow all regulatory guidelines for food and kitchen sanitation safety.
Repeat Deficiencies in QAA Program
Penalty
Summary
The facility's Quality Assessment and Assurance (QAA) program failed to maintain implemented procedures and monitor interventions following the recertification survey and an on-site revisit survey and complaint investigation. This resulted in three repeat deficiencies in the areas of Posted Nurse Staffing Information (F732), Residents Are Free of Significant Med Errors (F760), and Resident Records - Identifiable Information (F842). Specifically, the facility failed to accurately document the Daily Nursing Hours postings for 2 of 45 reports reviewed, did not follow physician orders for sliding scale insulin administration for two residents, and failed to accurately document the administration of narcotic pain medications and other prescribed medications in the electronic Medication Administration Record (eMAR). These deficiencies were noted during both the recertification survey and the revisit survey, indicating a pattern of the facility's inability to sustain an effective QAA program. In the case of medication errors, the facility did not administer sliding scale insulin as prescribed to two residents, resulting in missed doses. Additionally, the facility failed to follow physician orders for Zoloft and Novolog insulin administration, leading to missed and incorrect doses. The facility also did not accurately document the administration of medications in the eMAR, including scheduled and as-needed narcotic pain medications. These issues were compounded by staff turnover and a lack of monitoring by the facility Administrator, who acknowledged the failure to ensure accurate daily staff postings.
Failure to Document Narcotic Administration in eMAR
Penalty
Summary
The facility failed to accurately document the administration of prescribed as-needed narcotic pain medications in the electronic Medication Administration Record (eMAR) for two residents. For Resident #46, a dose of Percocet 10-325 mg was removed from the locked narcotic drawer by Nurse #1 on 03/19/24 at 6:49 PM, but it was not documented in the eMAR. Nurse #1 admitted to forgetting to sign off the medication in the eMAR due to being occupied with other medication passes at the time. Similarly, for Resident #177, multiple doses of Hydrocodone 10 mg-Acetaminophen 325 mg were removed from the locked narcotic drawer by Nurse #1 and Nurse #5 on 03/19/24 and 03/20/24, but these administrations were not documented in the eMAR. Nurse #1 stated she was unable to sign off the medication in the eMAR because it was locked, and she did not know how to unlock it. Nurse #5 admitted to forgetting to document the administration in the eMAR. Interviews with the Unit Manager and the Administrator revealed that there was an expectation for all medications to be accurately documented in both the narcotic record and the eMAR. The Unit Manager explained that if a nurse marked a medication as prepared but did not return to mark it as administered, the medication would lock in the eMAR, preventing further documentation. The Unit Manager was unsure who had the authority to unlock the medication in the eMAR since the departure of the previous Director of Nursing. The Administrator reiterated the expectation for accurate documentation of medication administration in both records.
Inaccurate Documentation of Daily Nursing Hours
Penalty
Summary
The facility failed to accurately document the Daily Nursing Hours postings for two specific dates. A review of the Payroll Based Journal (PBJ) Staffing Data Report for Fiscal Year - Quarter 1, 2024, revealed that there was no Registered Nurse (RN) coverage on four dates, including 10/08/23 and 12/03/23. However, the facility's Daily Nursing Hours postings inaccurately reported 8 RN hours for these two dates. Further review of the daily assignment sheets confirmed that no RN was present in the building on these dates. Interviews with the Payroll/Human Resources Coordinator and the Administrator corroborated that no RN was scheduled or paid for those days, despite the incorrect postings. The Administrator acknowledged the discrepancy but could not explain why the postings were incorrect, noting that an RN had been scheduled but did not show up for work on one of the days.
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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