Davis Health And Wellness Center At Cambridge Vill
Inspection history, citations, penalties and survey trends for this long-term care facility in Wilmington, North Carolina.
- Location
- 83 Cavalier Drive Ste 200, Wilmington, North Carolina 28405
- CMS Provider Number
- 345568
- Inspections on file
- 18
- Latest survey
- March 26, 2026
- Citations (last 12 mo.)
- 8
Citation history
Health deficiencies cited at Davis Health And Wellness Center At Cambridge Vill during CMS and state inspections, most recent first.
The facility failed to maintain the required eight consecutive hours of RN coverage per day on multiple occasions, despite having a census of fewer than 60 residents. Review of PBJ reports, daily census postings, staffing sheets, and timecards showed that on several days no RN was scheduled or worked the required continuous hours. The Administrator, who is responsible for ensuring RN coverage, acknowledged ongoing difficulties in maintaining this requirement, citing reliance on agency RNs and the unavailability of the prior DON when agency RNs did not report for their scheduled shifts.
The facility failed to obtain and document informed consent before initiating psychotropic antidepressant medications for seven cognitively intact or mildly impaired residents with conditions such as depression, anxiety, stroke, dementia, insomnia, and falls. Physician orders and MARs showed that medications including duloxetine, sertraline, amitriptyline, trazodone, bupropion, and Prozac were administered as ordered, but EMRs lacked evidence that residents or responsible parties were informed of the medication names, purposes, risks, benefits, alternatives, or their right to refuse, and there were no signed consent forms or progress notes reflecting consent discussions. In interviews, the Case Manager and DON reported they were unaware that consent was required for psychotropic medications and acknowledged the facility had not been obtaining informed consent, while the Physician stated she was unaware consent had not been obtained and affirmed that informed consent prior to starting psychotropic medications is essential.
Surveyors found that kitchen staff failed to discard multiple expired food items stored in a reach-in refrigerator, including opened containers of sauerkraut, canned pears, canned tuna, and canned pork and beans that were kept past their labeled discard dates. A weekend cook reported that all kitchen staff were responsible for checking and discarding expired foods but acknowledged he had not checked the refrigerator and had overlooked the expired items on a prior shift. The Dietary Manager stated that perishable foods were to be discarded after 3 days and that staff should have removed the items on their discard dates, while the Administrator stated she expected kitchen staff to check for and remove expired foods daily.
A resident with chronic osteomyelitis and diabetes had an order for doxycycline 100 mg PO twice daily, but over several days eight doses were not administered because the medication was unavailable or awaiting pharmacy delivery. Multiple nurses documented the missed doses on the MAR yet did not notify the physician, with some stating they did not think or realize notification was necessary. The DON stated she expected staff to notify the provider when medications are unavailable, and the physician reported being unaware of the missed doses and stated that medications should be administered as ordered and that the provider should be notified if a medication is not available.
A resident with chronic osteomyelitis and diabetes had an order for doxycycline 100 mg PO BID, but eight consecutive doses were not administered over several days because the medication was repeatedly unavailable. Multiple nurses documented the drug as unavailable, did not consistently check the automated dispensing machine, and often failed to contact the pharmacy or request use of the backup system, while one nurse learned of a discrepancy between the pharmacy’s once-daily entry and the facility’s BID order but did not escalate it to the DON or physician. The DON stated she expected medications to be administered as ordered and that staff should use the automated dispensing machine and backup pharmacy when medications are not on hand, and the Pharmacy Manager reported that the pharmacy had entered the order incorrectly and that, if notified, the medication would have been supplied through backup processes, noting the potential risk of infection worsening from the missed doses.
A resident receiving hydroxyzine 25 mg for pruritus continued to be administered the medication three times daily because a physician-approved change to twice-daily dosing, recommended in the Consultant Pharmacist’s monthly medication regimen review, was not entered into the EMR. The DON, who received the pharmacist’s emailed report and described a process for obtaining physician signatures and updating orders, did not promptly act on the December review, resulting in ongoing administration of the higher-frequency dose until the pharmacist later alerted her that the change had not been implemented.
Three residents experienced significant medication errors due to failures in medication availability, order transcription, and timely implementation of dose changes. One resident with chronic osteomyelitis missed multiple consecutive doses of doxycycline when several nurses documented the drug as unavailable and did not promptly secure it from the pharmacy. Another resident with depression and Parkinson’s disease received 15 mg of mirtazapine nightly instead of the intended 7.5 mg after the DON mis-entered the order and the facility’s two-step verification process was not completed. A third resident with pruritus continued to receive hydroxyzine 25 mg three times daily because a physician-approved dose reduction to twice daily, identified in a pharmacist’s medication regimen review, was not promptly entered into the EMR, and the higher-frequency dosing continued until the DON eventually updated the order.
Two residents with histories of falls and related diagnoses did not have person-centered care plans addressing fall risk, despite assessments indicating the need. Both experienced multiple falls during their stays, and the required care plans were not developed or updated due to missed actions by the MDS Nurse and lack of participation in weekly IDT meetings.
The facility failed to implement a comprehensive system to monitor antibiotic use, as required by their Antibiotic Stewardship Program policy, affecting all 18 residents over a 12-month period. Monthly reports lacked necessary data such as surveillance logs and trends in infection. Staff interviews revealed a lack of oversight and responsibility, with the Compliance Coordinator and DON unaware of the deficiencies in tracking and documentation.
Failure to Maintain Required Daily RN Coverage
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a Registered Nurse (RN) was on duty for at least eight consecutive hours per day, seven days a week, as required. Review of the Payroll Based Journal (PBJ) reports for the federal fiscal third and fourth quarters of 2025 showed days without the required RN coverage. Daily census posting sheets from April through September 2025 documented a consistent census of fewer than 60 residents and confirmed that on multiple specific dates there was no RN coverage for eight consecutive hours. Daily nursing staffing sheets for the same period also showed that no RN was scheduled for at least eight consecutive hours on those dates, and timecard records confirmed that no RN actually worked eight consecutive hours on those days. During an interview, the Administrator stated she was responsible for ensuring that an RN was scheduled to work eight consecutive hours each day and acknowledged ongoing difficulties in maintaining this required coverage since she began her role. She reported that the facility relied on agency nurses to fill RN shifts, and when an agency RN did not report for a scheduled shift, she was often unable to secure a replacement. She also noted that the previous Director of Nursing was unavailable during these times, which contributed to the gaps in the required RN coverage.
Failure to Obtain Informed Consent for Psychotropic Antidepressant Medications
Penalty
Summary
The deficiency involves the facility’s failure to obtain and document informed consent prior to initiating psychotropic antidepressant medications for seven residents reviewed for unnecessary medications. For each of these residents, physician orders were in place for various antidepressants, including duloxetine, sertraline, amitriptyline, trazodone, bupropion, and Prozac, and the Medication Administration Records (MARs) showed that the medications were administered as ordered. However, the electronic medical records (EMRs) contained no documentation that the residents or their responsible parties were informed in advance of the name and purpose of the medications, the risks and benefits, alternatives, or the right to refuse, and there were no signed informed consent forms or progress notes reflecting informed consent discussions. One resident admitted with depression had an order for duloxetine 30 mg twice daily, was documented as cognitively intact on the MDS, and received the antidepressant in February and March, but there was no record of informed consent. Another resident with stroke and depression had orders for sertraline 75 mg at bedtime and later amitriptyline 25 mg at bedtime for insomnia; the resident had mild cognitive impairment and received these medications, yet the EMR lacked any documentation of informed consent for either psychotropic medication. A third resident with stroke and depression, cognitively intact per MDS, received sertraline 150 mg daily and later 100 mg daily over several months, with MARs confirming administration, but again without any EMR documentation that risks and benefits were discussed or consent obtained. Additional residents were similarly affected. One cognitively intact resident with major depressive disorder, anxiety, falls, and muscle weakness had new orders for trazodone 50 mg at bedtime as needed for insomnia and bupropion SR 150 mg daily for depression, and received both medications, but there was no documentation of informed consent. Another cognitively intact resident with dementia and insomnia continued trazodone 50 mg at bedtime, and two cognitively intact residents with major depression received Prozac 10 mg daily and duloxetine 20 mg twice daily, respectively; in all three cases, MARs confirmed ongoing administration, but EMRs lacked any evidence that the residents or responsible parties were informed about the medications, including their purpose, risks, benefits, alternatives, or right to refuse, and there were no signed consent forms or progress notes documenting such discussions. Interviews with the Case Manager and DON confirmed they were not aware that consent was required for psychotropic medications and that the facility had not been obtaining informed consent prior to initiation, and the Physician stated she was unaware consent had not been obtained and that obtaining informed consent prior to initiating psychotropic medications was essential.
Failure to Discard Expired Food Items in Kitchen Refrigerator
Penalty
Summary
Surveyors observed that kitchen staff failed to discard multiple expired food items stored in one of two reach-in refrigerators, contrary to professional standards and facility expectations for food safety. During an initial kitchen tour on 03/22/26 at 10:20 AM with a staff member identified as #1, surveyors found an opened plastic container of sauerkraut with a discard date of 2/24/26, an opened plastic container of canned pears with a discard date of 3/12/26, an opened plastic container of canned tuna with a discard date of 3/19/26, and an opened plastic container of canned pork and beans with a discard date of 3/21/26 still stored in the refrigerator. In an interview at 10:25 AM on 03/22/26, the weekend cook (staff #1) stated that all kitchen staff were responsible for checking and discarding expired foods, acknowledged he had not checked the refrigerator that morning, and confirmed he had also worked the previous day when the expired items were overlooked. In a 03/24/26 interview at 12:42 PM, the Dietary Manager stated that perishable foods were to be discarded after 3 days and that staff should have removed the foods on their discard dates, and in a separate interview at 12:52 PM the Administrator stated she expected kitchen staff to check for expired foods daily and remove any foods by the discard date.
Failure to Notify Physician of Multiple Missed Antibiotic Doses
Penalty
Summary
The deficiency involves the facility’s failure to notify the physician when a resident missed multiple ordered doses of an antibiotic. The resident was admitted with diagnoses including chronic osteomyelitis and diabetes and had a physician’s order dated 2/13/26 for doxycycline 100 mg by mouth twice daily indefinitely for chronic osteomyelitis. Review of the March 2026 MAR showed that on 3/9/26, both the lunch and evening doses were documented as not administered due to the medication being unavailable, with no corresponding documentation in the nursing progress notes that the physician was notified. On 3/10/26, the lunch dose was again documented as not administered because the medication was unavailable, and the evening dose was not given while staff documented they were waiting for pharmacy delivery, with no evidence of physician notification. Further review showed that on 3/11/26, both the lunch and evening doses were not administered due to the medication being unavailable or awaiting pharmacy refill, and on 3/12/26, both the lunch and evening doses were also not administered because the medication was unavailable. In total, eight doses of doxycycline were missed without physician notification. Interviews with multiple nurses confirmed they did not inform the physician when the antibiotic was unavailable and not administered, with some nurses stating they did not think it was necessary or did not realize notification was required. The DON stated she expected medications to be administered as ordered and that staff should notify the provider when a medication is not available. The physician reported being unaware that the resident had missed eight doses of the prescribed antibiotic and stated that medications should be available and administered as ordered, and that the provider should be notified if a medication is not available.
Failure to Obtain and Administer Ordered Antibiotic Therapy
Penalty
Summary
The deficiency involves the facility’s failure to provide prescribed pharmaceutical services by not obtaining and administering doxycycline 100 mg twice daily as ordered for a resident with chronic osteomyelitis and diabetes. A physician order dated 2/13/26 directed that the resident receive doxycycline 100 mg by mouth twice per day indefinitely for chronic osteomyelitis. Review of the March 2026 MAR showed that eight consecutive doses of doxycycline were not administered on 3/9/26, 3/10/26, 3/11/26, and 3/12/26, with nurses documenting that the medication was unavailable, awaiting pharmacy delivery, or awaiting pharmacy refill. The physician later stated she was unaware that eight doses had been missed and indicated that medications should be available and administered as ordered. On 3/9/26, the nurse assigned from 7:00 AM to 7:00 PM documented that the lunch dose was not given because the medication was unavailable in the resident’s medication cabinet and acknowledged she did not check the automated medication dispensing machine or contact the pharmacy or local backup pharmacy. Another nurse documented the evening dose on 3/9/26 as unavailable and not administered. On 3/10/26, one nurse documented the lunch dose as unavailable and not administered, and another nurse documented the evening dose as waiting for pharmacy delivery and not administered. On 3/11/26, the day nurse documented the lunch dose as unavailable and awaiting pharmacy refill, and reported that she did not check the automated dispensing machine or contact the pharmacy, assuming the medication would arrive later. On the nights of 3/11/26 and 3/12/26, the night nurse reported that the doxycycline was not in the resident’s medication cabinet and that, although she checked the automated dispensing machine, the correct dose was not available there. She acknowledged that she did not contact the pharmacy on 3/11/26 and, when she did call on 3/12/26, she did not request that the medication be sent through the backup system and did not report the discrepancy in dosing frequency between the pharmacy’s once-daily entry and the facility’s twice-daily order to the DON or physician. The DON stated she expected medications to be administered as ordered and that nurses should notify the pharmacy and use the automated dispensing machine and local backup pharmacy when medications were not available. The Pharmacy Manager reported that the pharmacy had systems for daily availability, including twice-daily deliveries and backup processes, and stated that if notified, the doxycycline would have been sent through the backup system; he also confirmed the pharmacy had entered the order as once daily instead of twice daily and acknowledged the potential risk for worsening of the infection due to the missed doses.
Failure to Implement Pharmacist-Recommended Change in Hydroxyzine Dosing
Penalty
Summary
The deficiency involves the facility’s failure to act on a Consultant Pharmacist’s monthly medication regimen review and update a resident’s hydroxyzine order in the electronic medical record after the physician had signed to change the order. Resident #8, admitted with diagnoses including pruritus, had a physician’s order dated 7/10/23 for hydroxyzine 25 mg three times a day for pruritus. The Consultant Pharmacist’s Medication Regimen Review dated 1/12/26 documented that on 12/12/25 the physician signed the pharmacy consult report to change the hydroxyzine to 25 mg every morning and midday and discontinue the three-times-daily dosing. However, this new order was not entered into the electronic medical record. Review of the Medication Administration Record from 12/12/25 through 1/18/26 showed that Resident #8 continued to receive hydroxyzine 25 mg three times a day, as evidenced by nursing signatures, indicating the original order remained in effect despite the physician-approved change. The Director of Nursing reported that the Consultant Pharmacist emailed monthly medication regimen reviews and described a process in which physician recommendations from these reviews were to be placed in a physician’s notebook and, once signed, entered into the electronic record. The DON stated she was new to the facility in December 2025 and did not promptly address the December pharmacy reports, resulting in a delay in implementing the reduced hydroxyzine dosing until the Consultant Pharmacist notified her the following month that the frequency had not been changed. The Clinical Compliance Administrator confirmed that medication regimen reviews were expected to be addressed as soon as the DON received them.
Multiple Medication Administration and Order-Entry Errors Affecting Three Residents
Penalty
Summary
The deficiency involves multiple significant medication errors affecting three residents. One resident with chronic osteomyelitis and diabetes had a physician order dated 2/13/26 for doxycycline 100 mg by mouth twice daily indefinitely. Review of the March 2026 MAR showed that eight consecutive doses of doxycycline, both midday and evening, were not administered over four days, with nurses documenting that the medication was unavailable, awaiting pharmacy delivery, or awaiting refill. Several nurses who were assigned to the resident during this period acknowledged that the ordered antibiotic was not given and reported that they did not contact the pharmacy to obtain the medication, or only did so after multiple missed doses. The physician later stated she had been unaware that eight doses were missed and characterized the failure to administer the prescribed antibiotic as a significant medication error. A second deficiency involved a resident admitted with major depression and Parkinson’s disease. The hospital discharge summary ordered mirtazapine 15 mg, one-half tablet by mouth at 11:00 PM. However, on 2/27/26 the DON entered an order in the electronic record for mirtazapine 15 mg by mouth at bedtime, resulting in the resident receiving a full 15 mg tablet nightly instead of the intended 7.5 mg dose. The MAR from 2/27/26 through 3/10/26 showed that 15 mg doses were administered each night, and there was no documentation during that period of any clarification or correction of the dose by the prescriber. The DON later stated she had transcribed the order incorrectly and that the facility’s two-step verification process for new orders was not completed for this medication. A third deficiency concerned a resident admitted with pruritus who had a physician’s order dated 7/10/23 for hydroxyzine 25 mg three times daily. A consultant pharmacist’s medication regimen review dated 1/12/26 noted that the physician had signed a prior pharmacy consult report from 12/12/25 to change the hydroxyzine to 25 mg every morning and midday and discontinue the three-times-daily schedule, and requested that the electronic record be corrected and the medication error reported. Despite this, the MAR from 12/12/25 through 1/18/26 showed the resident continued to receive hydroxyzine 25 mg three times daily. The physician’s order in the electronic record was not updated to twice daily until 1/19/26. The DON stated she was new to the role, received the monthly pharmacist reviews, and did not promptly address the December report, resulting in the resident continuing on the higher frequency dosing until the order was finally changed. Across these three cases, surveyors identified failures in ensuring medications were available and administered as ordered, accurate transcription of physician orders, and timely implementation of pharmacist-recommended order changes. The pharmacy manager stated that the pharmacy had systems for daily medication availability and backup processes, and acknowledged the potential risk associated with missing multiple doses of an antibiotic. The DON stated she expected medications to be administered as ordered and that nursing staff should contact the pharmacy when medications were not available, but in these instances, staff either did not contact the pharmacy in a timely manner or did not correct orders in the electronic record, leading to prolonged deviations from prescribed regimens.
Failure to Develop and Implement Fall Risk Care Plans
Penalty
Summary
The facility failed to develop and implement person-centered care plans addressing fall risk for two residents who had documented histories of falls and related diagnoses. For the first resident, who was cognitively intact and had a left knee fracture, the Minimum Data Set (MDS) admission assessment triggered the need for a fall risk care plan, but none was created. This resident experienced multiple falls during their stay, as documented in nursing progress notes and event reports, yet the care plan was not updated to address fall risk. The MDS Nurse confirmed that the care area assessment for falls was triggered and acknowledged that a fall risk care plan should have been initiated but was missed. The MDS Nurse also did not attend weekly interdisciplinary team (IDT) meetings where care plans were to be reviewed and updated, and the Interim Director of Nursing (DON) confirmed that the care plan should have been updated during these meetings. Similarly, the second resident, who had severe cognitive impairment and a history of falls, also did not have a fall risk care plan in place despite the MDS assessment triggering the need for one. This resident experienced several falls during their stay, as documented in nursing progress notes. The MDS Nurse again confirmed that the fall risk care plan was not developed as required and stated it was missed. The Interim DON reiterated that the care plan should have been updated during weekly IDT meetings, but the MDS Nurse's absence from these meetings contributed to the deficiency. The Administrator confirmed that the MDS Nurse was responsible for developing the fall risk care plans for both residents.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement a comprehensive system to monitor antibiotic use, as required by their Antibiotic Stewardship Program policy. This deficiency was evident over a 12-month period from January 2024 to December 2024, affecting all 18 residents in the facility. The monthly antibiotic summary reports reviewed did not include necessary information such as surveillance logs, microbiology testing results, or trends in infection, nor did they document the antibiotics ordered. The facility's policy, last revised in February 2023, required the review of essential data including antibiotic orders and infection trends, which was not adhered to. Interviews with facility staff revealed a lack of oversight and responsibility for the antibiotic stewardship program. The Compliance Coordinator, who was SPICE trained and responsible for overseeing the Infection Control Program, was unaware that the previous Infection Preventionist had not completed the necessary surveillance or tracking of infections. The Director of Nursing, who assumed the role of Infection Preventionist in December 2024, acknowledged receiving a list of antibiotics from the pharmacy but had not documented antibiotic use or tracked infections. The interim Administrator, in position since January 2025, recognized the need for a comprehensive infection control program but was unaware of the reasons for the lack of tracking and trending of infections and antibiotic use prior to her tenure.
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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