Copperfield Health & Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Concord, North Carolina.
- Location
- 515 Lake Concord Road Ne, Concord, North Carolina 28025
- CMS Provider Number
- 345130
- Inspections on file
- 25
- Latest survey
- February 27, 2026
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Copperfield Health & Rehabilitation during CMS and state inspections, most recent first.
A cognitively intact resident with bipolar disorder, schizophrenia, and a documented history of aggression repeatedly physically abused other residents when they entered or altered his environment. A severely cognitively impaired, wheelchair‑bound resident with Alzheimer’s dementia twice wandered into his room and, on each occasion, was struck in the face, resulting in a bruised, swollen, and lacerated lip, swelling to the jaw, and swelling and bruising around the eyebrow. Later, a newly admitted resident with Parkinson’s disease and normal cognition reported that, after using his call light to request a temperature change, the same aggressive resident approached his bed, yelled, cursed, spat at him, and struck him multiple times on the head and upper body, leaving him feeling unsafe and victimized. The psychiatric NP and Medical Director acknowledged that the aggressive resident was cognitively intact, aware of his actions, and had developed a pattern of striking out when others entered or changed his environment.
The facility failed to follow the planned menu for residents on mechanically altered diets when, on two observed lunch meals, a resident with dysphagia, protein calorie malnutrition, lipoprotein deficiency, and severe cognitive impairment received vegetables and desserts that did not match the therapeutic diet spreadsheet. Instead of the specified soft, fork-mashable vegetables and designated desserts, the resident was served alternate vegetables, fruit, and a cookie. The Dietary Manager and Regional Dietary Manager confirmed that all residents on mechanically altered diets received incorrect vegetables and desserts on those days due to the facility running out of food, and the Administrator stated that staff were expected to follow the menu and document and communicate any changes.
Surveyors found multiple open, unlabeled, and unsealed food items with signs of frostbite, discoloration, spoilage, and past use-by dates in the kitchen walk-in freezer and refrigerator. Items included chicken tenderloins and breasts, chocolate chip cookies, biscuit dough, shredded parmesan cheese, herb thyme, and pimento cheese spread. The Dietary Manager and Administrator acknowledged that facility practice requires all opened food to be labeled with an open date, kept closed and sealed, discarded if spoiled, and used or discarded according to use-by policies, and that the dietary department is responsible for daily food storage and safety.
A resident with CHF, COPD, and chronic respiratory failure had a physician order for continuous O2 at 3 L/min via nasal cannula, but repeated observations showed the bedside flowmeter set at 2 L/min. The cognitively intact resident reported that staff sometimes set her O2 at 2 L/min when she was in her wheelchair, despite her understanding that it should be 3 L/min. Nursing staff documented in the eMAR that O2 was given at 3 L/min on multiple shifts, while later stating they believed the ordered liter flow was being delivered and one nurse reported relying on the resident’s prior preference for 2 L/min and being unaware of an updated order. Unit management and leadership stated they were not aware of the incorrect liter flow and indicated that staff were expected to follow MD orders and verify correct O2 settings.
A resident with severe cognitive impairment was subjected to abuse and privacy violations by two nurse aides who live-streamed the resident's care to a prison inmate. The aides used vulgar language, failed to explain care, and exposed the resident's naked body, violating the resident's rights and dignity.
A resident's privacy was violated when two nurse aides live-streamed personal care to a prison inmate, exposing the resident without consent. The aides, despite being educated on privacy policies, engaged in this act, compromising the resident's dignity. The incident was captured on video, revealing a lack of effective monitoring and enforcement of privacy policies in the facility.
A resident in a LTC facility was subjected to abuse when two nurse aides failed to identify, intervene, or report the incident. The resident, who was severely cognitively impaired, was live-streamed naked from the waist up, with staff using profanity and physical aggression during care. The incident involved a prison inmate viewing the live stream, violating the resident's privacy and rights. The facility's inadequate abuse policy enforcement led to this immediate jeopardy situation.
A resident's oxycodone medication was misappropriated due to discrepancies in the narcotic count verification sheet, with signatures appearing forged and numbers overwritten. The facility's investigation revealed that one card of oxycodone was missing, and Nurse #2, responsible for the medication cart, refused to provide a statement. The pharmacy and police were notified, and the facility failed to protect the resident's medication from misappropriation.
A resident with limited range of motion and intact cognition did not receive necessary nail care and hand hygiene assistance from the facility. Despite requests, nursing assistants did not provide nail care due to time constraints, and the resident was observed scratching her skin without subsequent hand hygiene before meals. The Director of Nursing was unaware of these unmet care needs, indicating a deficiency in care practices.
The facility failed to conduct quarterly smoking assessments for two residents, one with severe cognitive impairment and another with moderate impairment, leading to a deficiency in accident prevention. Despite the care plan requirements and computer notifications, staff were unaware of the missed assessments, compromising supervision and safety.
The facility did not date three opened bottles of artificial tears in the B-hall medication cart, contrary to the manufacturer's recommendations that they be discarded after 28 days. Nurse #5 noted the absence of dates on the bottles, although the date was reportedly on the box the previous evening. Both the DON and the Administrator confirmed that the bottles or boxes should have been dated upon opening.
The facility failed to provide written transfer notifications to two residents or their representatives when they were sent to the hospital for medical issues. One resident, who was severely cognitively impaired, was transferred multiple times without notification, while another resident, who was cognitively intact, was also transferred without notification. The Social Worker had not been issuing these notices, and the Administrator was unaware of this deficiency.
Failure to Protect Residents From Repeated Physical Abuse by an Aggressive Resident
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from abuse by not adequately managing a cognitively intact resident with a known history of aggression toward others. This resident had diagnoses including anxiety, violent behavior, bipolar disorder, paranoid schizophrenia, dementia with mood disturbance, and insomnia, and was receiving antipsychotic, antianxiety, and antidepressant medications. His care plan documented a history of verbal aggression, poor impulse control, and threatening statements toward peers, with interventions such as 1:1 activity as needed, monitoring behavior episodes, explaining procedures, allowing time to adjust to changes, and psychiatric/behavioral services as needed. Despite this known history and care plan, the resident repeatedly engaged in physical aggression toward other residents. In the first incident, a severely cognitively impaired resident who was fully dependent for ADLs (except eating) and used a manual wheelchair entered the aggressive resident’s room. Staff did not witness the event, but the roommate called out for help, and staff found the cognitively impaired resident outside the doorway with a bruised, swollen, cut upper lip that had been bleeding. Nursing staff and the on‑call provider documented that the injuries were consistent with being struck in the mouth with a closed fist, and the aggressive resident told a nurse he hit the other resident because he did not want her in his room. The facility was aware of the aggressive resident’s past aggressive behaviors toward residents and staff prior to this event. In a subsequent incident involving the same two residents, the aggressive resident again spat on, cursed at, and punched the severely cognitively impaired resident when she wandered into his room. The cognitively impaired resident sustained swelling and bleeding of the lip and jaw, swelling and bruising of the upper lip, and swelling of the right eyebrow, and she was unable to reliably communicate pain. Documentation noted that she had been assaulted by the same resident two months earlier. Later, a newly admitted resident with Parkinson’s disease and normal cognition reported that, after activating his call light to request a lower room temperature, the same aggressive resident approached his bed, yelled, cursed, spat at him, and struck him multiple times on the head and upper body. The new resident reported feeling victimized, unsafe, and as though he had to sleep with one eye open. The aggressive resident told staff he spit on and punched this roommate because he believed he was going to be kicked. The Psychiatric NP and Medical Director both stated that the aggressive resident was cognitively intact, aware of his actions, and had developed a pattern of striking out when others entered or altered his environment, and that he would likely respond the same way again if not redirected by staff.
Failure to Follow Planned Menu for Mechanically Altered Diets
Penalty
Summary
The facility failed to follow the planned menu for residents prescribed mechanically altered diets during two observed lunch meals. A resident with protein calorie malnutrition, lipoprotein deficiency, dysphagia, and severe cognitive impairment was ordered a mechanically altered diet with thin liquids. The facility’s diet spreadsheet for therapeutic diets showed that residents on mechanically altered diets were to receive specific soft, cooked, fork-mashable vegetables and designated desserts for the lunch meals observed. However, during the first lunch observation, the resident’s tray ticket listed a regular mechanically altered diet, but the actual meal included broccoli with mixed vegetables and tropical fruit instead of the planned seasoned sautéed zucchini and applesauce. There was no evidence of the menu-specified vegetable or dessert on the tray. During the second lunch observation, the diet spreadsheet indicated that residents on mechanically altered diets, including this resident, should receive ground turkey cutlet with gravy, mashed potatoes, cut green beans, and cherry cobbler. Instead, the resident was served chopped turkey cutlet with gravy, red whole sliced potatoes, broccoli, and a cookie for dessert. The Dietary Manager acknowledged awareness of the resident’s mechanically altered diet and confirmed that the resident received the wrong vegetables and dessert, and that all 24 residents on mechanically altered diets received incorrect vegetables and desserts on both observed days. The Regional Dietary Manager stated the facility had run out of food, leading to menu changes, and confirmed that 24 residents on mechanically altered diets did not receive the correct vegetables or desserts. The Administrator stated her expectation that dietary staff follow the planned menu and log and communicate any menu changes to residents.
Improper Labeling, Storage, and Discarding of Food in Kitchen Walk-in Units
Penalty
Summary
The deficiency involves failure to properly label, date, seal, and discard food items in the facility’s walk-in freezer and refrigerator in accordance with professional standards. During an initial kitchen observation with the Regional Dietary Manager and the Dietary Manager, surveyors found in the walk-in freezer an opened, unsealed package of chicken tenderloins and an opened, unlabeled, unsealed package of chicken breasts, both with frostbite spots and grayish-brown discoloration. They also observed an opened, unlabeled, unsealed box of chocolate chip cookies with frostbite and grayish-brown discoloration, and an opened, unlabeled, unsealed package of biscuit dough with ice crystal formation. In the walk-in refrigerator, surveyors observed an opened, unlabeled 5-lb bag of parmesan fancy shredded cheese, an opened, unlabeled, unsealed box of herb thyme that appeared spoiled with brownish/blackish discoloration, and an open 1-quart container of pimento cheese spread with a use-by date that had already passed. In interviews, the Dietary Manager stated that open food items should be checked weekly, labeled with an open date, and kept closed and sealed, and acknowledged that the freezer items should not have been opened and needed to be discarded. The Administrator stated that all food and beverage items should be dated when opened, food showing signs of spoilage should be discarded, and items should be used or discarded according to use-by policies, confirming that the dietary department is responsible for daily food storage and safety.
Failure to Administer Ordered Oxygen Liter Flow and Accurate eMAR Documentation
Penalty
Summary
The deficiency involves the facility’s failure to administer oxygen as ordered by the physician for a resident with congestive heart failure, COPD, and chronic respiratory failure. The resident was admitted with these diagnoses and had a physician’s order dated 10/02/2025 for continuous oxygen at 3 liters per minute via nasal cannula for shortness of breath. The quarterly MDS indicated the resident was cognitively intact, received oxygen therapy, and used a non-invasive mechanical ventilator. On multiple observations on 02/16/2026, 02/17/2026, and 02/18/2026, the resident’s oxygen via nasal cannula connected to the bedside oxygen flowmeter was found set at 2 liters per minute instead of the ordered 3 liters per minute. During an interview, the resident stated that her oxygen was supposed to be set at 3 liters per minute and reported that when she was placed in her wheelchair, nursing staff sometimes set the oxygen at 2 liters instead of the prescribed 3 liters. She stated staff informed her of the oxygen setting and the amount remaining in the tank because the equipment was positioned behind her wheelchair. Review of the eMAR showed that Nurse #6 documented that the resident received oxygen at 3 liters per minute on 02/16/2026, 02/17/2026, and 02/18/2026 on first shift, and Nurse #7 documented that the resident received oxygen at 3 liters per minute on 02/17/2026 and 02/18/2026 on night shift, despite the observed setting of 2 liters per minute. Nurse assignment sheets confirmed that Nurse #6 and Nurse #7 were responsible for the resident’s care on the dates in question. In an interview, Nurse #6 acknowledged that the oxygen was set at 2 liters per minute and confirmed the physician’s order for 3 liters per minute continuously. She stated the resident had told her months earlier to set the oxygen at 2 liters based on home use and that the resident had been receiving 2 liters previously; she was unaware of the updated order for 3 liters per minute. Nurse #6 explained that the eMAR allowed her to document oxygen as administered by selecting yes or no and that she documented yes because she believed the resident was receiving 3 liters per minute. Nurse #7 similarly stated she documented oxygen as administered because she believed the resident was receiving 3 liters per minute. Unit Manager #1 stated that if oxygen was set at the wrong liter flow it was to be corrected immediately and that nursing staff should routinely check oxygen settings, but she had not previously noticed an incorrect setting for this resident. The NP stated that, due to the resident’s COPD, oxygen must be maintained at the prescribed liter flow, and the DON and Administrator both reported they were unaware that the resident’s oxygen was not being administered at the prescribed setting, while stating that staff were expected to follow physician orders.
Resident Abuse and Privacy Violation During Care
Penalty
Summary
The facility failed to protect a resident's right to be free from abuse, as evidenced by an incident involving two nurse aides who provided personal care to a severely cognitively impaired resident while live streaming the event on a cell phone. The resident, who was naked from the waist up, was exposed to vulgar and profane language by the staff and a prison inmate who was watching the live stream. The staff did not explain the care being provided to the resident and were physically aggressive during the care process. The incident was captured on video footage provided by the Sheriff Department, which showed the staff's inappropriate behavior and the resident's exposure to the inmate and other inmates in the background. The resident involved in the incident was admitted to the facility with diagnoses including anxiety, Alzheimer's disease, dementia, and mood disturbance. The resident required extensive assistance with two-person support for bed mobility and transfers and was noted to be severely cognitively impaired. Despite having adequate hearing and vision and the ability to understand others, the resident was subjected to a lack of dignity and respect during the care process. The staff's actions, including undressing the resident without explanation and engaging in inappropriate conversations, violated the resident's rights and privacy. Interviews conducted with the involved staff members revealed that they had been educated on abuse and neglect policies but denied any wrongdoing. The Director of Nursing and Administrator were unaware of any staff using cell phones in care areas or taking pictures or videos of residents. The facility's failure to enforce policies prohibiting personal cell phone use in resident care areas and to protect the resident's privacy and dignity led to the deficiency. The incident was reported to Adult Protective Services and the local police department, highlighting the severity of the abuse and exploitation experienced by the resident.
Removal Plan
- All current facility staff were in-serviced on the Abuse, Neglect and Exploitation Policy, Resident Rights Policy and Cell Phone Policy.
- Education of proper resident care includes ensuring residents are not harmed physically or handled roughly during care.
- Facility is adopting a NO TOLERANCE Cell Phone Policy focusing on the strict prohibition of cellular phones and any type of electronic recording device use in resident care areas.
- Abuse questionnaires were completed with current facility staff to validate competency of education received and to identify any additional allegations or incidence of resident abuse.
- The Administrator, DON or designee will complete ongoing observational rounds of facility residents and staff to ensure that residents are free from abuse and resident rights to privacy is maintained.
- Facilities new hire screening process has been updated to include additional measures to better determine the candidate's probability of providing excellent resident care.
Resident Privacy Violated During Live Stream by Staff
Penalty
Summary
The facility failed to protect the privacy of a resident who was severely cognitively impaired. Two nurse aides, while providing personal care to the resident, live-streamed the event on a cell phone to a prison inmate. During this live stream, the resident was exposed, naked from the waist up, and the event was visible to multiple inmates and a guard in the prison's open area. The resident's privacy was violated as the live stream showed the resident being undressed and transferred without consent. The incident was captured on video footage provided by the Sheriff's Department, which showed the nurse aides engaging in the live stream while providing care to the resident. The video revealed that the aides were laughing and interacting with the inmate during the call, further compromising the resident's dignity and privacy. The aides did not use privacy curtains or take measures to ensure the resident's privacy during the care process. Interviews with the involved staff and facility administration revealed that the aides had been educated on resident privacy and the prohibition of cell phone use in care areas. Despite this, the aides denied taking part in the video call or recording the resident. The facility's Director of Nursing and Administrator were unaware of any staff using phones in care areas, indicating a lack of effective monitoring and enforcement of privacy policies.
Removal Plan
- The DON suspended NA #1 pending outcome of abuse investigation and notified the Medical Director of allegation.
- The Social Worker notified the local police department and adult protective services (APS) and obtained a police report number.
- The Administrator submitted the initial allegation report to North Carolina Department of Health Human Services (NCDHHS).
- The Administrator completed an observational round of facility residents and staff to ensure that resident's right to privacy is maintained.
- The DON, VPCO, VPRQA, Administrator and Medical Director held an Ad Hoc meeting to discuss incident to determine root cause analysis.
- The DON immediately suspended NA #2, notified Resident #2 resident representative(s) and the MD, and the VPRQA notified local law enforcement and APS with updated information.
- The VPCO assessed Resident #2 for physical injury, pain and signs or symptoms of psychosocial distress.
- The facility attempted to obtain information regarding the location of the prison to inquire on the security of the recording.
- All current facility staff were in-serviced on the Resident Rights Policy, CMS guidance 483.10(h) and the Cell Phone Policy.
- Questionnaires were completed following in-servicing with current facility staff to validate competency of education received.
- The Administrator, DON or designee will complete observational rounds of facility residents and staff to ensure that resident's right to privacy is maintained.
- Licensed nurses were educated and notified by the VPCO of their responsibility to complete observational rounds each shift for his/her unit.
- The Administrator is ultimately responsible for the implementation and completion of this removal plan.
Failure to Implement Abuse Policies Leads to Resident Abuse
Penalty
Summary
The facility failed to develop and implement effective abuse policies, resulting in a significant deficiency involving a resident. During an incident, two nurse aides were present in a room with a resident who was being abused. The aides did not identify the abuse, intervene to stop it, or report it immediately to licensed or administrative staff. This lack of action occurred while the resident was being live-streamed on a cell phone, exposing the resident to further abuse and violation of privacy. The resident involved was severely cognitively impaired, and the abuse included being shown naked from the waist up during a live stream. The staff involved used profanity and vulgarity, and the resident was subjected to physical aggression during care. The live stream was viewed by a prison inmate, further compounding the abuse and violation of the resident's rights. The reasonable person concept was applied, indicating that a reasonable person would have been traumatized by such treatment in their home environment. The facility's failure to protect the resident's right to be free from abuse was compounded by the staff's inaction and the lack of immediate reporting. The incident highlighted the facility's inadequate system for ensuring staff knowledge and enforcement of the Abuse, Neglect, and Exploitation Policy, as well as the Cell Phone Policy. This deficiency was identified as immediate jeopardy, indicating a severe risk to resident safety and well-being.
Removal Plan
- All current facility staff were in-serviced on the Abuse, Neglect and Exploitation Policy, Resident Rights Policy and Cell Phone Policy.
- Abuse training topics included preventing, reporting and identifying what constitutes abuse and NO TOLERANCE for failure to comply and ensure resident protection.
- Education of proper resident care includes ensuring residents are not harmed physically or handled roughly during care but are provided with care that is gentle, kind, dignified and that residents are free from offensive comments, profanities or other form of verbal abuse.
- The facility is adopting a NO TOLERANCE Cell Phone Policy focusing on the strict prohibition of cellular phones and any type of electronic recording device use in resident care areas.
- Training included examples of violation of residents' privacy and the potential effects on residents whose privacy is not maintained.
- Abuse questionnaires were completed with current facility staff to validate competency of education received and to identify any additional allegations or incidence of resident abuse.
- The Administrator, DON or designee will complete ongoing observational rounds of facility residents and staff to ensure that residents are free from abuse and resident rights to privacy is maintained.
- Licensed nurses were educated and notified of their responsibility to complete observational rounds for his/her unit and observe resident and staff interactions.
- The facilities new hire screening process has been updated to include additional measures to better determine the candidate's probability of providing excellent resident care.
- Human Resources (HR) and/or the Administrator, DON or SDC are responsible for the interview process, screening reference checks and screening social media platforms.
- The facility will NOT extend employment to any candidate with convictions or pending convictions involving elder abuse, neglect or exploitation.
- The Administrator is ultimately responsible for the implementation and completion of this removal plan.
Misappropriation of Controlled Medications
Penalty
Summary
The facility failed to protect a resident's right to be free from misappropriation of controlled medications. A resident with a diagnosis of chronic pain was prescribed oxycodone 10 mg every 6 hours. On a specific date, the facility received a delivery of four cards of oxycodone, each containing 10 tablets. However, it was discovered that one card of oxycodone was missing, and the shift change narcotic count verification sheet had been altered. The signatures on the sheet appeared to be forged, and the numbers were overwritten, indicating a discrepancy in the narcotic count. The investigation revealed that Nurse #2 was responsible for the medication cart on the day the discrepancy was noted. Despite attempts to contact her, Nurse #2 refused to provide a statement regarding the missing medication. The facility's Director of Nursing conducted a review and confirmed that one card of oxycodone was missing, and the shift change narcotic count sheet had been tampered with. The pharmacy and police were notified of the incident, and Nurse #2 was suspended pending further investigation. Interviews with other nursing staff indicated that the narcotic count was correct at the beginning of the day shift, but discrepancies were noted during the shift change. The facility's President of Quality confirmed that the Administrator and the Director of Nursing were no longer employed at the facility. The investigation concluded that the missing oxycodone card was not accounted for, and the facility failed to maintain accurate records and protect the resident's medication from misappropriation.
Failure to Provide Nail Care and Hand Hygiene for a Dependent Resident
Penalty
Summary
The facility failed to provide adequate nail care and hand hygiene for a dependent resident, identified as Resident #65, who required assistance with all activities of daily living. Resident #65, who had an intact cognition and a diagnosis of limited range of motion, was observed with long, uneven nails with black matter underneath, indicating a lack of proper nail care. Despite the resident's requests for nail care, the nursing assistants (NAs) assigned to her care did not provide the necessary assistance due to time constraints and heavy workloads. The resident was also observed scratching her skin, including inside her undergarment, without subsequent hand hygiene being offered before meals. Interviews with the NAs and the Director of Nursing (DON) revealed a lack of communication and awareness regarding the resident's need for nail care and hand hygiene. The NAs admitted to not providing nail care during bed baths and not informing the nurse of the resident's condition. The Activity Assistant also noted that a scheduled manicure activity was not completed due to time limitations. The DON was unaware of the resident's unmet care needs and the lack of hand hygiene provided before meals, highlighting a deficiency in the facility's care practices for dependent residents.
Failure to Conduct Quarterly Smoking Assessments
Penalty
Summary
The facility failed to complete quarterly smoking assessments for two residents, leading to a deficiency in ensuring a safe environment free from accident hazards. Resident #31, who was admitted with diagnoses including hypertension, muscle weakness, dementia, and blindness in one eye, was identified as a supervised smoker due to severe cognitive impairment and non-compliance with the smoking policy. Despite the care plan's requirement for regular smoking assessments, only one assessment was completed since the last recertification, indicating a lapse in monitoring the resident's smoking habits. Similarly, Resident #72, with diagnoses of hypertension and unsteadiness of feet, was assessed as an independent smoker. However, the facility failed to conduct quarterly smoking assessments as required, with a significant gap between assessments. Interviews with staff, including a nurse, unit manager, and the Director of Nursing, revealed a lack of awareness and oversight regarding the missed assessments, despite the computer system's notifications for pending assessments. This oversight contributed to the deficiency in maintaining adequate supervision to prevent accidents related to smoking.
Failure to Date Opened Bottles of Artificial Tears
Penalty
Summary
The facility failed to properly date three opened bottles of artificial tears stored in the B-hall medication cart, as observed during a survey. According to the manufacturer's recommendations, these bottles should have been discarded 28 days after opening. During an observation, Nurse #5 revealed that the bottles were found without an open date, although she mentioned that the date was on the box the previous evening. Both Nurse #5 and the Director of Nursing acknowledged that either the bottle or the box should have been dated when the bottle was opened. The Administrator also confirmed this requirement during an interview.
Failure to Provide Written Transfer Notifications
Penalty
Summary
The facility failed to provide timely written notification of hospital transfers to residents or their representatives, as required by regulations. This deficiency was identified for two residents who were transferred to the hospital for medical issues. Resident #27, who was severely cognitively impaired, was transferred to the hospital on multiple occasions for various health concerns, including difficulty swallowing, a fall with head pain, and intractable nausea and vomiting. Despite these transfers, there was no documentation of written transfer notifications in the resident's medical record. Similarly, Resident #28, who was cognitively intact, was sent to the hospital for cellulitis, elevated white blood cells, and elevated kidney function. The medical record for this resident also lacked a written transfer notification. Interviews with the Social Worker revealed that she had not been providing written notices of transfer, despite being informed by the previous administrator that it was necessary. The current Administrator was unaware of this lapse and expected that such notifications were being provided.
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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