Durham Nursing & Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Durham, North Carolina.
- Location
- 411 S Lasalle Street, Durham, North Carolina 27705
- CMS Provider Number
- 345070
- Inspections on file
- 32
- Latest survey
- April 16, 2026
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Durham Nursing & Rehabilitation Center during CMS and state inspections, most recent first.
The facility failed to maintain an effective pest control program and adequate sanitation in the kitchen, resulting in ongoing German roach activity despite regular pest control treatments. Pest control records and dietary logs documented repeated roach sightings in food service areas, and a surveyor observed a live roach moving into dry storage. The pest control technician reported persistent infestation due to uncorrected structural issues such as cracks, holes, and open areas around pipes, as well as chronic food debris and grease buildup. The Dietary Manager acknowledged ongoing roach activity, lacked a formal deep‑cleaning schedule, and relied on staff to clean as they worked, while multiple dietary staff reported seeing live roaches regularly. The Maintenance Director and Administrator were aware of needed repairs and cleaning issues in the kitchen but had not ensured completion of repairs or verification of thorough cleaning, contributing to the continued pest problem.
A cognitively intact resident with significant ADL needs and a long-standing preference for Tuesday and Thursday morning showers had his shower schedule moved from first shift to second shift when new ownership and a new DON implemented a building-wide shower schedule to improve structure and workflow. The DON made this change without consulting residents about their preferences. After the change, the resident repeatedly told multiple staff he wanted his original first-shift shower times restored, but staff told him the schedule could not be changed. A nurse and a NA confirmed the resident’s prior first-shift schedule and his ongoing requests, and the family member reported that his requests had gone unaddressed for months. Although the DON acknowledged the concern and delegated a review of the shower schedule to a UM, the UM was not specifically informed of this resident’s request and did not start reevaluating the schedule, resulting in the resident’s expressed choice for shower time not being honored.
A cognitively intact resident reported that both a previous and a current bathroom were in poor condition, including dirty shower tile, wall damage near the toilet and shower, lack of a toilet grab bar, and a broken toilet tank lid. Surveyors observed a large area of blackish-brown substance on the shower floor and wall, damaged sheetrock, a makeshift wood panel attached to the wall, a broken ceramic toilet tank lid, and a bathroom floor with multiple layers of chipped paint. In the prior room, they observed sheetrock damage beside the toilet, a damaged and rusted door frame, and a painted tile floor with extensive chipping. Review of maintenance records showed only one completed work order for a grab bar installation in the current room and none for the prior room, while the Maintenance Director and Administrator acknowledged longstanding awareness of these bathroom conditions and other needed repairs throughout the facility.
A resident with diabetes and a history of basal cell carcinoma developed an itchy scalp lesion that was treated with topical medications per NP orders, but an ordered dermatology consult was never completed. Although the NP documented from the outset that dermatology should evaluate the lesion and later noted the resident’s repeated inquiries about the consult, no appointment was scheduled. A nurse signed off the dermatology order as completed, yet the transportation staff member who later assumed appointment‑scheduling duties was unaware of the need for the visit and could not find a referral. The dermatology clinic reported it had requested additional information from a former appointment scheduler and never received a response, and facility leadership could not verify that the dermatology appointment had ever been arranged.
A resident was admitted with an unstageable sacral pressure ulcer documented in hospital records, but the hospital discharge summary did not include wound care orders. On admission, nursing staff noted an unstageable coccyx wound and care plans referenced treatment "as ordered," yet no wound care orders were present on the TAR and no wound care was documented for several days. Multiple nurses who cared for the resident during this period reported they either did not provide wound care or would only have done so if orders existed. The wound care nurse later assessed the sacral ulcer, found the original hospital dressing still in place, noted the absence of wound care orders, and then entered the first treatment order, with the first documented wound care occurring that same day. Leadership and the NP stated that staff were expected to obtain wound care orders when missing but were unaware that this had not occurred for this resident.
The facility failed to label medications with resident names, discard expired medications, and store medications according to manufacturer instructions. Insulin pens and compounded omeprazole suspensions were found expired, and latanoprost eye drops were improperly stored. The DON confirmed the need for proper labeling, storage, and disposal of medications.
A resident with cognitive impairment and limited mobility was repeatedly found with their call bell out of reach, preventing them from requesting assistance. Despite being alert and able to communicate, the resident's call bell was tied to the bed rail and often on the floor, as confirmed by staff observations and interviews.
The facility inaccurately coded MDS assessments for three residents, leading to discrepancies in their medical records. A resident with schizophrenia was incorrectly coded for PASRR Level I instead of Level II, and another resident was wrongly noted as receiving insulin instead of hypoglycemic medication. Additionally, a resident was inaccurately recorded as receiving antianxiety medication. These errors were acknowledged by the staff involved.
A facility failed to post cautionary signage outside a resident's room to indicate the use of supplemental oxygen. The resident, admitted with hypoxia, was on continuous oxygen therapy at 2 L/min via nasal cannula. Observations confirmed the absence of signage, and staff interviews revealed that the responsibility for posting signage was with the admitting nurse or Unit Manager, which was missed.
A resident with a history of stroke reported numbness and pain in his left side to nurse aides, but the nursing staff failed to assess the condition or notify the physician. The resident's symptoms worsened, leading to a delayed diagnosis of an ischemic stroke. The lack of timely assessment and communication resulted in the resident being outside the treatment window for Alteplase, a stroke medication.
A facility failed to implement necessary medical interventions for a resident with untreated sleep apnea, leading to severe health decline and hospitalization. Despite physician orders for a CPAP machine and consultations, these were not executed due to transportation issues. Another resident with stroke symptoms was not comprehensively assessed, resulting in delayed treatment and critical care admission. These deficiencies highlight the facility's failure to respond to significant changes in residents' conditions.
The facility failed to conduct annual performance reviews for five nurse aides, as required by regulations. The Director of Nursing and Staff Development Coordinator, both recently hired, were unaware of the facility's process for maintaining nurse aide competency skills training and performance reviews. The Administrator confirmed that due to turnover in the Staff Development Coordinator position, there was no evidence of completed training and education, resulting in a lack of documentation for the required annual performance reviews.
A resident with obstructive sleep apnea did not receive a Pulmonary consultation or a CPAP machine due to transportation issues, despite physician orders. The resident also missed a Neurology consultation for migraines. Facility staff were aware of the transportation difficulties but did not resolve them, leading to missed critical medical appointments.
The facility was cited for deficiencies in food safety and equipment maintenance. A dietary aide handled food without gloves or facial hair covering, and the kitchen was not clean. Food items in the walk-in cooler were not properly labeled, and the dish machine failed to reach the required temperature. Insulated dome lids were stored wet. The dietary supervisor and maintenance director acknowledged these issues.
The facility failed to maintain a clean environment, with growth buildup found in and on an ice machine. Observations revealed blackish-brown spots and pinkish/black matter on the machine, and blackish matter, light beige growths, and yellow material on the floor and molding. The Maintenance Director was unaware of the issue, and the Administrator was uncertain about the deep clean schedule.
A privacy breach occurred when a medication cart laptop was left unattended, displaying resident health information in a public area. Nurse #4 admitted the oversight, and both the DON and Administrator confirmed the need to lock the laptop screen when unattended.
A medication cart in Zone 1 was found unlocked and unattended, with staff and residents passing by. Nurse #3, who was administering evening medications, later locked the cart. The cart contained resident medications, including insulin pens and medicated ointments. The DON confirmed that medication carts should be locked when unattended.
A resident with obstructive sleep apnea did not receive a CPAP machine as documented by a physician. The resident reported never having the machine or seeing a pulmonologist, despite the physician's note indicating CPAP use. The DON confirmed the resident never had the machine, and the facility failed to monitor the physician's documentation.
A resident did not receive their prescribed Liraglutide due to the facility's failure to notify the pharmacy of the missing medication. Despite procedures in place, nursing staff did not contact the pharmacy, leading to missed doses. The physician and administrator highlighted the lack of communication and questioned the pharmacy's delivery system.
A resident with diabetes and kidney failure did not receive prescribed medications due to unavailability. Nurses failed to administer insulin and Liraglutide as ordered, and did not consistently notify the physician about the medication shortages. The DON and physician confirmed that staff should have followed orders and communicated medication issues.
A resident with cerebral palsy and contractures sustained a mildly displaced left medial malleolus fracture during an unsafe transfer using a sit-to-stand lift. The resident's ankle got caught in the wheelchair, leading to significant pain and the need for emergency room evaluation. The facility staff followed protocols for pain management and further evaluation, and the resident's care plan was updated to use a mechanical lift for transfers.
The facility's QAA committee failed to develop and implement an effective plan to prevent accidents, resulting in repeated unsafe transfer incidents. One resident sustained a fracture during a sit-to-stand lift transfer, and another incident involved a mechanical lift tipping, requiring staff intervention to prevent injury.
Failure to Maintain Effective Pest Control and Sanitation in Kitchen
Penalty
Summary
The deficiency involves the facility’s failure to maintain an effective pest control program in the kitchen, as evidenced by ongoing German roach activity and inadequate sanitation and structural maintenance. Pest control service summaries over several months documented repeated German roach activity in the kitchen, including in the dishwasher electrical box, near the coffee station, and in food warming equipment. The pest control technician repeatedly noted needed repairs such as cracks in walls and floors, broken tiles and baseboards, standing water from poorly functioning drains, and greasy cooking equipment that were providing harborage for roaches and undermining control efforts. Despite weekly and bi‑weekly pest control treatments, the technician reported that an active infestation remained and that he typically observed at least one live roach during each visit. During a kitchen observation with the Dietary Manager, a live roach was seen on the floor in front of the dry storage doorway and then entering the dry storage area. The Dietary Manager acknowledged ongoing live roach activity, particularly under the steam table and in other warm areas. Inspection beneath the steam bar revealed multiple layers of food debris, a dessert cup with food, disposable lids, a fork, dust, and dirt, indicating that the area had not been cleaned. Dietary stand‑up meeting reports and pest control logs documented multiple pest sightings over several weeks, including roaches in the bottom of the gas oven and dish room, and ants and flies around the steam table and gas stove. The Dietary Manager stated there was no formal deep‑cleaning schedule for the kitchen and that she relied on staff to clean as they worked and to perform periodic deep cleaning. Multiple dietary staff members reported seeing live roaches regularly in the kitchen, although they felt the activity had improved somewhat since a change in facility ownership. One cook/aide stated he sees live roaches regularly but ignores them. The pest control technician described persistent sanitation problems, including consistent food crumbs, flour, dough, and other food debris on the floor, and layers of food debris, dust, and dirt behind equipment, under shelves, and beneath the steam bar that appeared not to have been cleaned for a long time. The Maintenance Director confirmed awareness of holes, cracks, damaged trim and molding, open areas around plumbing pipes, a water leak under a sink, peeling paint, and damaged tiles in the kitchen, but acknowledged that these repairs had not yet been completed. The Administrator stated he was aware of repairs, cleaning issues, and pest sightings reported in morning stand‑up meetings, but he did not verify that cleaning was being done and did not make routine rounds in the kitchen, while continuing to review pest service summaries and compare pest control company pricing. Overall, the combination of ongoing roach sightings documented by dietary staff and pest control logs, visible live roaches during surveyor observation, accumulated food debris and lack of a formal deep‑cleaning schedule, and unaddressed structural defects such as cracks, holes, and open areas around pipes led to the facility’s failure to maintain an effective pest control program in the kitchen. The pest control technician’s repeated identification of sanitation and repair issues, along with the Maintenance Director’s and Administrator’s acknowledgment of known but uncorrected problems, further demonstrate the inaction that contributed to the continued presence of roaches in food service areas.
Failure to Honor Resident’s Established Shower Time Preference
Penalty
Summary
The deficiency involves the facility’s failure to honor a cognitively intact resident’s established choice of shower time after a change in ownership and scheduling. The resident, who had spastic diplegic cerebral palsy, contractures of the right hand and both knees, chronic kidney disease, and required extensive assistance with ADLs including bathing, had long received showers on Tuesdays and Thursdays during first shift (7:00 AM to 3:00 PM). In January 2026, after new owners assumed control, the DON created a new shower schedule that moved the resident’s showers to second shift (3:00 PM to 11:00 PM) without speaking with residents beforehand or assessing their preferences. The written shower schedule at the nurse’s station reflected this change, listing the resident for showers on Tuesdays and Thursdays on second shift. The resident reported that no one informed him in advance that his shower times would be changed and that he was not asked whether he wanted to alter his long-standing schedule. After learning of the change, he repeatedly told multiple staff members that he did not want showers on second shift and wanted his original first-shift schedule restored, but he was told the schedule could not be changed. He stated that this had been ongoing since January and that he found the situation frustrating, as he believed it was his right to have his preference honored. The resident’s family member corroborated that he had been requesting a return to first-shift showers since the schedule change and that his requests were not acted upon. Nursing staff interviews confirmed that the resident had historically received showers on first shift and that the DON changed his shower times in January as part of a new structured schedule. A nurse and a nursing aide both stated that the resident had been asking to have his showers moved back to first shift and that his preferences had been communicated to administrative staff, with the aide reporting she was told by the DON that the time could not be changed. The DON acknowledged she created the new schedule to improve structure and workflow, did not consult residents before making the changes, and later delegated review of the schedule to a unit manager without specifically directing her to address this resident’s request. The unit manager stated she did not begin reevaluating the shower schedule and was not informed that this resident wanted his shower times changed, despite the DON’s awareness of the concern. This sequence of actions and inactions resulted in the facility not honoring the resident’s expressed choice regarding shower time.
Failure to Maintain Resident Bathrooms in Safe, Clean, and Homelike Condition
Penalty
Summary
The facility failed to maintain resident bathrooms in safe, clean, and homelike condition for a cognitively intact resident whose rooms on one hall had longstanding disrepair and cleanliness issues. The resident reported that his previous and current bathrooms were in poor condition, describing dirty shower tile, lack of a grab bar near the toilet, wall damage by the toilet and shower, and a broken toilet tank lid in his current room, as well as visible sheetrock patching and large spots on the painted tile floor in his prior room. He stated he had not used the shower and did not know how long the bathroom had been in this condition, and recalled reporting these issues in the past but could not remember to whom. Review of work orders from the beginning of the year through mid-April showed only one completed work order related to his current room, which was for installation of a grab bar in the bathroom, and no work orders for his prior room; no earlier work orders were available. Surveyor observations confirmed extensive physical damage and unclean conditions in both bathrooms used by the resident. In the current room, the shower had a blackish-brown substance covering a large area of the shower floor and up the left wall, the wall between the toilet and shower had sheetrock damage at the base, a piece of wood had been screwed to the wall on the right side of the toilet, and the ceramic toilet tank lid was broken with a missing corner. In the prior room, there was sheetrock damage extending up the wall beside the toilet, a damaged door frame with missing paint and visible rust, and a bathroom floor consisting of painted tile with multiple areas of chipping paint exposing different colors beneath. The Maintenance Director acknowledged awareness of the poor condition of both bathrooms, attributing some of the deterioration to water damage and stating that many rooms and bathrooms were already in this condition when the current company assumed operations, and that repairs were being prioritized based on severity. The Administrator also acknowledged awareness that several rooms throughout the facility needed repair.
Failure to Schedule Ordered Dermatology Follow-Up for Resident With Skin Cancer History
Penalty
Summary
The deficiency involves the facility’s failure to ensure a dermatology follow‑up appointment was scheduled as ordered for a resident with a history of basal cell carcinoma. The resident was admitted with diabetes and a history of basal cell carcinoma of the head, neck, and skin. In early December, a NP documented a sore on the top of the resident’s head and indicated that a dermatology appointment was to be made by nursing. On January 27, the NP again evaluated the wound, described it as nickel‑sized and caused by scratching, and ordered topical treatment, which records show was administered as ordered. On January 30, a physician order was entered for a dermatology consult as needed for possible basal cell carcinoma on the top of the head, noting the resident’s history of basal cell carcinoma. This order was signed off as completed by a nurse, but there is no documentation that an appointment was actually scheduled. Subsequent NP progress notes in February and March continued to reference the need for a dermatology appointment, including a plan to schedule dermatology to evaluate and treat the wound and documentation that the resident was inquiring about the dermatology consultation for possible basal or squamous cell carcinoma. The wound was described as healed but with ongoing redness, inflammation, irritation, and intermittent itching around the scabbed area. During an interview and observation in April, the resident had a scabbed area on the scalp and reported a history of skin cancer and being told months earlier that a dermatology visit was needed, but he was unsure if an appointment had been made and felt it had been forgotten. The resident transportation staff member, who had assumed responsibility for scheduling appointments after the prior appointment scheduler left, stated she was unaware of the need for a dermatology appointment and could not locate a referral. She later learned from the dermatology clinic that a referral had been received and that the clinic had requested additional information from the former scheduler but never received a response. The NP, unit manager, DON, and administrator each described that referrals or orders should be printed and given to the appointment scheduler, but none could confirm that a dermatology appointment had been scheduled for this resident, resulting in the ordered consult not being carried out.
Failure to Obtain and Implement Timely Wound Care Orders for Existing Sacral Pressure Ulcer
Penalty
Summary
The deficiency involves the facility’s failure to assess and obtain timely treatment orders for a resident admitted with an existing sacral pressure ulcer. Hospital records from 12/31/25 to 1/23/26 documented a hospital-acquired unstageable pressure injury to the sacrum, and the resident was admitted on 1/23/26 with diagnoses including end stage renal disease on hemodialysis and a sacral pressure ulcer. The hospital discharge summary did not include wound care orders for the sacral wound. On admission, Nurse #13 documented an unstageable skin impairment to the coccyx in the admission assessment and nursing progress note, but provided no further description of the wound, and there is no evidence that wound care orders were obtained at that time. From 1/23/26 through 1/26/26, multiple nurses cared for the resident without providing documented wound care to the sacral pressure ulcer. The care plan initiated on 1/23/26 identified skin impairment and included an intervention for treatment as ordered, but there were no wound care orders on the Treatment Administration Record during this period. Nurse #7, who cared for the resident on 1/24/26, could not recall providing wound care and stated she would only have done so if an order was present. Nurse #3, who cared for the resident on 1/26/26, stated she did not provide wound care that day. Attempts to contact other involved nurses, including Nurse #8 and Nurse #13, were unsuccessful, and there is no documentation that any nurse contacted the NP or on-call provider to obtain wound care orders during these days. The wound care nurse, Nurse #5, completed an admission skin assessment on 1/27/26, documenting a sacral pressure ulcer measuring 2 cm by 2 cm and noting that the bandage in place was from the hospital. She recalled that there were no wound care orders on the resident’s Treatment Administration Record at that time and could not recall if she reported this to anyone. On that same date, 1/27/26, Nurse #5 entered the first wound care order for cleansing the sacral ulcer with 1/4 strength Dakin’s solution, applying calcium alginate, and covering with super absorbent foam, and the first documented treatment occurred that day. The NP and nursing leadership, including the unit manager and DON, stated their expectation that admitting nurses and the wound care nurse would ensure wound care orders were obtained when not present on hospital discharge paperwork, but they were unaware that this resident had no wound care orders from 1/23/26 to 1/26/26.
Medication Labeling and Storage Deficiencies
Penalty
Summary
The facility failed to properly label medications with the minimum required information, including the resident's name, on one of the medication carts observed. During an observation, an in-use prefilled pen of Insulin Glargine-yfgn was found on the medication cart without a resident's name, and the expiration date indicated it had expired 11 days prior. Additionally, an in-use prefilled pen of Insulin Lispro for a resident was found with an expiration date that had passed 17 days before the observation. There was no indication of when these insulin pens were dispensed or put into use. The facility also failed to discard expired medications on two medication carts and in the medication storeroom. In the medication storeroom, an opened vial of Novolin R insulin was stored without a date indicating when it was opened, and it had been dispensed 111 days prior. Two bottles of compounded omeprazole suspension were found with expiration dates that had passed 37 and 2 days before the observation, respectively. These expired medications were confirmed by the nursing staff during the observation. Furthermore, medications were not stored according to the manufacturer's instructions on one of the medication carts. An unopened bottle of latanoprost eye drops, which should be refrigerated, was found stored on the medication cart. The Director of Nursing confirmed that medications needed to be labeled correctly, stored as instructed, and expired medications should be discarded or returned to the pharmacy. The facility's unit managers were expected to perform weekly checks to ensure compliance with these requirements.
Resident's Call Bell Out of Reach
Penalty
Summary
The facility failed to ensure that a resident's call light was within reach, which is necessary for the resident to request staff assistance. The resident, who was moderately cognitively impaired and dependent on staff for all activities of daily living, was observed multiple times with the call bell out of reach. The resident had impairments in both upper and lower extremities, requiring substantial to maximum assistance for movement. Despite being alert and able to communicate needs, the resident was unable to reach the call bell, which was tied to the bed rail and often found on the floor. Observations and interviews with staff, including a nurse and the Director of Nursing (DON), confirmed that the call bell was not within the resident's reach on several occasions. The DON acknowledged the issue and repositioned the call bell within reach during an observation. Staff interviews revealed that the resident was alert, oriented, and able to use the call bell, but the staff had not noticed it was out of reach. The resident required total assistance for care and could not reposition independently, highlighting the importance of having the call bell accessible.
Inaccurate MDS Coding for Residents
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) assessments for three residents, leading to discrepancies in their medical records. Resident #23, who was diagnosed with major depressive disorder and schizophrenia, was inaccurately coded as having a PASRR Level I status instead of Level II, despite her care plan correctly reflecting the Level II status. Additionally, her MDS assessment incorrectly indicated that she received an insulin injection, while her records showed she was on hypoglycemic medications like Ozempic and glipizide, with no insulin administered during the specified period. Resident #52, diagnosed with schizoaffective disorder, was incorrectly coded as having received an antianxiety medication during the 7-day lookback period on her MDS assessment. However, her medical records and interviews with staff confirmed that she did not receive any antianxiety medication during that time. This discrepancy was acknowledged by the MDS nurse responsible for the assessment. Resident #4, with a diagnosis of type 2 diabetes mellitus, was inaccurately coded as receiving insulin on her MDS assessment. In reality, she was receiving Ozempic for weight management, not insulin. The MDS Coordinator misinterpreted the drug classification, leading to the error. Interviews with the resident and nursing staff confirmed that she was not on insulin, highlighting a misunderstanding of the medication classification system used by the facility.
Failure to Post Oxygen Signage for Resident on Supplemental Oxygen
Penalty
Summary
The facility failed to post cautionary signage outside a resident's room to indicate the use of supplemental oxygen. This deficiency was identified for a resident who was admitted with a diagnosis of hypoxia and had a physician's order for oxygen supplementation at 2 liters per minute via nasal cannula. Observations on multiple occasions revealed that the resident was receiving continuous oxygen therapy, but there was no signage outside the room to indicate this. The absence of signage was noted during observations on different days and times. Interviews with facility staff, including a nurse and the Director of Nursing (DON), confirmed that the responsibility for placing oxygen signage on a resident's door fell to the admitting nurse or the Unit Manager. The DON acknowledged that the signage was missed by the nurses, indicating a lapse in the facility's protocol for ensuring safety measures were in place for residents receiving oxygen therapy.
Failure to Notify Physician of Resident's Change in Condition
Penalty
Summary
The facility failed to notify the physician and responsible party of changes in condition for a resident with a history of stroke and intact cognition. On the evening of 10/21/24, the resident reported pain and numbness in his left arm and leg to a nurse aide, who informed the nurse. However, the nurse did not assess the resident or notify the physician. The resident continued to experience symptoms, including an inability to feel his left side, which he reported to another nurse aide on the next shift. Again, the nurse was informed but did not conduct an assessment or notify the physician. The situation escalated when the resident was found by a unit manager on the morning of 10/22/24 with slurred speech and paralysis on his left side. The nurse practitioner assessed the resident and arranged for his transfer to the emergency department, where he was diagnosed with an ischemic stroke. The delay in assessment and notification resulted in the resident being outside the window for administering Alteplase, a medication used to treat ischemic strokes. Interviews with staff revealed a lack of communication and failure to follow protocol in assessing and reporting the resident's change in condition. The nursing staff did not document any progress notes regarding the resident's condition on 10/21/24 or 10/22/24 until after the unit manager's assessment. This deficiency in communication and documentation contributed to the delay in the resident receiving timely medical intervention.
Removal Plan
- Identify those recipients who have suffered, or are likely to suffer a serious adverse outcome as a result of the noncompliance.
- An audit to determine if any residents had reported any new change in condition that was not reported to the healthcare provider by a licensed nurse of residents with a brief interview for mental status (BIMS) score of 13 or higher was completed by the Administrator.
- An audit was completed by the Director of Nursing of progress notes to ensure that anyone reporting a change of condition had provider notification.
- The Director of Nursing questioned all of the licensed nurses regarding knowledge of any residents having had a change in condition that deviated from their baseline and did not have healthcare provider notification.
- The Director of Nursing or Staff Development Coordinator interviewed all nursing assistants regarding knowledge of any residents having change of conditions that were not reported to the healthcare provider.
- The Director of Nursing initiated education to all licensed nurses to complete a clinical assessment of a minimum vital signs and pertinent body systems once notified of a change in condition.
- Education included any changes reported by nursing assistants.
- Any licensed nurse that has not been educated will be taken off the schedule until the education has been received.
- All new hires will be educated by the Director of Nursing during orientation.
- The Regional Director of Clinical Services educated the Administrator, The Director of Nursing, Staff Development Coordinator, and The Human Resource Director on the orientation process for nursing staff.
- The Director of Nursing/Staff Development Coordinator re-educated all nursing assistants on change in condition of residents to include recognizing signs and symptoms of a stroke.
- Any nursing assistant that has not received the education will be taken off the schedule until the education has been received.
Failure to Implement Medical Orders and Assess Changes in Condition
Penalty
Summary
The facility failed to comprehensively assess and implement necessary medical interventions for a resident with untreated obstructive sleep apnea, leading to a significant decline in the resident's health. Despite physician orders for a CPAP machine, a pulmonology consultation, a neurology consultation, and an x-ray, these were not executed due to transportation issues and lack of follow-through. The resident experienced periodic abdominal pain, changes in mental status, and migraines over six months, with elevated CO2 levels noted in lab results. On one occasion, the resident was excessively sleepy, difficult to rouse, and had no oral intake, leading to an emergency medical intervention where the resident was found to be hypoxic and in a comatose state. Another resident with a history of stroke reported numbness and pain in the left arm and leg, which was not comprehensively assessed by the nursing staff. The resident's condition worsened overnight, and by the next morning, the resident exhibited symptoms of a stroke, including slurred speech and vision changes. The resident was eventually transferred to the emergency department, diagnosed with a cerebral vascular accident, and admitted to the critical care stroke unit. The delay in assessment and intervention resulted in the resident being outside the window for effective stroke treatment. These deficiencies highlight the facility's failure to identify and respond to significant changes in residents' conditions, leading to immediate jeopardy situations. The lack of comprehensive assessments and timely medical interventions for both residents resulted in severe health outcomes, including hospitalization and critical care admissions.
Removal Plan
- The facility failed to comprehensively assess a resident who had untreated obstructive sleep apnea to determine the root cause of periodic abdominal pain, change in mental status, and migraines in conjunction with elevated CO2 levels on labs.
- The facility also failed to implement physician's orders for a CPAP, pulmonology consultation, neurology consultation, x-rays and ultrasound.
- The nurse practitioner performed a comprehensive assessment and recommended that she be transferred to hospital.
- Resident was comprehensively assessed by the nurse practitioner who recommended she go to the hospital.
- Resident was diagnosed in the hospital with altered mental status, acute respiratory failure, acute kidney injury, transaminitis, and migraines.
- Resident was placed on a BIPAP and admitted to an intensive care unit.
- She received IV Lasix and supplemental oxygen.
- An Ultrasound was done due to transaminitis which demonstrated steatosis.
- Resident received an order for Fioricet for migraines.
- Resident's pulmonary and neurology consultations were discontinued upon discharge to hospital.
- Upon return to the facility, Resident did not have any new orders for pulmonology consultation or follow up as she currently has BIPAP in place.
Failure to Conduct Annual Performance Reviews for Nurse Aides
Penalty
Summary
The facility failed to complete annual performance reviews for five nurse aides, as required by healthcare regulations. The employee files for these nurse aides did not contain the necessary performance review documents for the years 2023 and 2024. The Director of Nursing, who was hired in May 2024, was unaware of the facility's process for maintaining nurse aide competency skills training and performance reviews. She could not provide evidence of any training done prior to her employment. Similarly, the Staff Development Coordinator, hired in August 2024, was also unaware of the facility's process and had not started reviewing employee training files or conducting annual performance evaluations. The Administrator confirmed that nurse aides' skills assessments and competencies should be completed at hire and annually, along with a performance review. However, due to turnover in the Staff Development Coordinator position, there was no evidence that the required training and education were completed and documented. The facility was unable to provide documentation indicating that the nurse aides' annual performance reviews were completed, highlighting a lapse in maintaining proper records and ensuring compliance with mandatory requirements.
Failure to Provide Necessary Medical Consultations and Equipment
Penalty
Summary
The facility failed to ensure that a resident with obstructive sleep apnea received a necessary Pulmonary consultation and a CPAP machine, as ordered by the physician. The initial order for a Pulmonary consultation and CPAP machine was made in April 2024, and a subsequent order was made in May 2024. However, the resident never attended the consultation or received the CPAP machine due to transportation issues. The resident was also ordered to attend a Neurology consultation in August 2024 for constant migraines, but this appointment was also missed due to the same transportation difficulties. The resident, who was admitted with multiple diagnoses including tachycardia, asthma, morbid obesity, and obstructive sleep apnea, did not have a CPAP machine upon admission. The resident's medical record showed no evidence of receiving the CPAP machine or attending the required consultations. Interviews with the physicians, transport staff, and the resident confirmed the lack of follow-through on these medical orders. The transport staff indicated that the resident's size required non-emergency stretcher transport, which was difficult to arrange due to the transport company's availability. The facility's staff, including the Unit Manager, Nurse Practitioner, and Director of Nursing, were aware of the transportation issues but did not resolve them, resulting in the resident missing critical medical appointments. The resident reported experiencing excessive sleepiness, memory issues, headaches, and abdominal pain over the past six months, which were not addressed due to the missed consultations. The facility's administrator acknowledged the transportation issues but did not provide comments on the lack of follow-through with the resident's appointments.
Food Safety and Equipment Maintenance Deficiencies
Penalty
Summary
The facility was found to have several deficiencies in its food service operations. Observations revealed that a dietary aide was handling food without wearing gloves or a facial hair covering, despite having facial hair. The dietary supervisor confirmed that facial hair coverings and gloves should be used during food preparation. Additionally, the kitchen environment was not maintained in a clean state, with the 3-compartment sink heavily soiled and containing food debris, a greasy substance, and a deceased insect. The maintenance director acknowledged the need for repairs in the dishwashing area, where decaying wooden material was observed. Further issues were identified in the walk-in cooler, where food items such as unshelled hard-cooked eggs and an opened jar of grape jelly were found without proper labeling or dating. The dietary supervisor admitted responsibility for checking the cooler daily but failed to notice these items. The dish machine used for cleaning dishware was also problematic, as it was not reaching the required minimum temperature of 120 degrees Fahrenheit during wash and rinse cycles. The dietary aide operating the machine did not consistently check the temperature, and the dietary supervisor had to contact the vendor for a service call. Lastly, the facility failed to ensure that insulated dome lids and bases were dry before being stored. A dietary aide admitted to rushing and not allowing the items to dry properly. The dietary supervisor and administrator both acknowledged that items should be properly dried before storage. These deficiencies highlight lapses in food safety practices and equipment maintenance within the facility.
Unsanitary Conditions in Ice Machine
Penalty
Summary
The facility failed to maintain a clean and sanitary environment, as evidenced by the presence of growth buildup in and on one of the two ice machines observed. During an inspection, blackish-brown spots were found on the external facing of the ice machine, and pinkish/black colored matter was observed on the internal ceiling and metal lip of the machine. Additionally, the floor and corner molding behind the ice machine exhibited blackish matter, light beige puffy growths, and yellow matted stringy material. The Maintenance Director was unaware of the ice machine's condition and stated that the machines were cleaned quarterly. He had not received any concerns from staff regarding mold in the ice machine. The Administrator mentioned that ice machines were checked weekly by staff and maintenance, but was uncertain about the deep clean schedule for the machines.
Privacy Breach of Resident Health Information
Penalty
Summary
The facility failed to maintain the privacy of a resident's medical records when a medication cart laptop was left unattended with resident health information exposed. This incident occurred with one of the four medication carts, specifically the Zone 1 medication cart. During an observation, the laptop was found displaying personal health information, including names, medications, and diagnoses, in an area accessible and visible to the public. Staff and residents were observed passing by the medication cart during this time. Nurse #4, responsible for the medication cart, acknowledged in an interview that she should have closed or locked the laptop screen to prevent exposure of resident information. The Director of Nursing (DON) and the Administrator both confirmed in their interviews that the laptop screen should have been locked before leaving the medication cart unattended.
Unattended and Unlocked Medication Cart
Penalty
Summary
The facility failed to secure resident medications in an unattended medication cart, specifically the Zone 1 medication cart. On the specified date and time, the medication cart was observed to be unlocked and unattended, with the locking mechanism in the unlocked position. During this period, staff and residents were seen passing by the unsecured cart. Nurse #3 was later observed approaching the cart from a resident's room and subsequently locking it. In an interview, Nurse #3 acknowledged that the cart should have been locked when not attended. The cart contained various resident medications, including insulin pens, medicated ointments, and eye drops. The Director of Nursing confirmed that medication carts should be locked when not attended by staff.
Failure to Provide CPAP Machine for Resident with Sleep Apnea
Penalty
Summary
The facility failed to maintain an accurate medical record for a resident regarding the use of a Continuous Positive Airway Pressure (CPAP) machine. The resident, who was admitted with multiple diagnoses including obstructive sleep apnea, was documented in the quarterly Minimum Data Set (MDS) as not having a CPAP machine. However, a physician's note dated June 19, 2024, indicated that the resident was to be initiated on CPAP settings and was stable to continue using the CPAP machine at night. Despite this, the resident reported never having received a CPAP machine or having seen a pulmonologist, which was necessary to obtain the machine. Interviews with the physician and the Director of Nursing (DON) revealed a lack of communication and monitoring of the physician's documentation. The physician was under the impression that the resident had received the CPAP machine, while the DON confirmed that the resident never had a CPAP machine prior to her hospitalization. The facility did not review or monitor the physician's documentation, leading to the oversight that the resident did not receive the necessary equipment for her obstructive sleep apnea.
Failure to Notify Pharmacy of Missing Insulin
Penalty
Summary
The facility failed to notify the pharmacy of missing insulin for a resident, leading to the resident not receiving their prescribed Liraglutide, an anti-diabetic medication, on multiple occasions. The physician's order required the administration of Liraglutide subcutaneously once a day, but the medication was not administered on specific dates in July 2024 due to it being on hold. The Medication Administration Record (MAR) indicated the medication was unavailable, yet there was no documentation of efforts to obtain it from the pharmacy. Interviews with nursing staff revealed a lack of communication with the pharmacy regarding the missing medication. The Director of Nursing (DON) and the consulting pharmacist confirmed that the facility had procedures for notifying the pharmacy when medications were low or unavailable, but these procedures were not followed. The physician expressed concern over not being informed about the medication's unavailability and questioned why the pharmacy did not automatically deliver the medication. The administrator also acknowledged that nursing staff should have contacted the pharmacy to obtain the medication for administration.
Failure to Administer Prescribed Medications
Penalty
Summary
The facility failed to follow physician orders for a resident with type 2 diabetes and kidney failure, leading to significant medication errors. The resident did not receive the prescribed insulin, Tresiba FlexTouch, on a specific date because the medication was not available. Nurse #2, who was responsible for administering the medication, realized the absence of insulin during her shift and notified the Director of Nursing (DON), who then contacted the pharmacy. However, there was no documentation of the insulin being administered on that day. Additionally, the resident did not receive another prescribed medication, Liraglutide, on multiple occasions. The Medication Administration Record (MAR) indicated that the medication was on hold due to unavailability. Several nurses, including agency nurses, were involved in the administration process but failed to ensure the medication was available or to notify the physician about the unavailability. Interviews with the DON and the physician confirmed that staff should have contacted the physician when medications were not available and should have followed the physician's orders as written.
Resident Injury During Unsafe Transfer
Penalty
Summary
The facility failed to safely transfer a resident using a sit-to-stand lift, resulting in the resident sustaining a mildly displaced left medial malleolus fracture and experiencing significant pain. The resident, who had a history of cerebral palsy, contractures, and previous left knee fusion surgery, was dependent on staff for transfers and other activities of daily living. During the transfer, the resident's ankle got caught in the wheelchair, leading to the injury. The incident was reported by the nurse aide to the assigned nurse, who then assessed the resident and administered pain medication as per physician orders. An X-ray confirmed the fracture, and the resident was sent to the emergency room for further evaluation and treatment, including the application of a CAM boot and prescription of pain medication. The resident was discharged back to the facility the same day. The nurse aide involved in the incident was an agency staff member who worked sporadically at the facility. He did not recall the type of mechanical lift used during the transfer and only realized the resident's leg was caught after the transfer was completed. The nurse aide received in-service training on mechanical lift transfers after the incident. The assigned nurse and the physician were both notified of the incident and took appropriate steps to manage the resident's pain and ensure further evaluation. The Director of Nursing confirmed that the resident required staff assistance for transfers and that the incident occurred during a sit-to-stand lift transfer. The resident's care plan was subsequently updated to reflect the use of a mechanical lift for transfers. The facility's Director of Nursing and Administrator were both aware of the incident and confirmed that the facility followed protocols to ensure the resident's safety. The Director of Nursing stated that the nurse aides were retrained on mechanical lift transfers, and the resident's care plan was updated to reflect the change in transfer method. The Administrator reviewed the interventions put in place and confirmed that they were effective, as no further incidents had occurred.
Repeat Issues with Resident Transfers Highlight QAA Failures
Penalty
Summary
The facility's Quality Assessment and Assurance (QAA) committee failed to self-identify the need for the development and implementation of an effective plan to achieve and sustain compliance in the area of supervision to prevent accidents. This was evidenced by a repeat issue with staff failing to transfer residents safely. Specifically, an incident occurred where a resident was transferred using a sit-to-stand lift, resulting in the resident sustaining a mildly displaced left medial malleolus fracture and experiencing significant pain. Another incident involved a mechanical lift tipping to one side, requiring two staff members to lower the resident to the floor without injury. During an interview, the facility's Administrator stated that the QAA committee was scheduled to meet at least quarterly but typically met about once a month. The Administrator acknowledged that after the first incident, the resident was transferred using a mechanical lift instead of a sit-to-stand lift. However, no performance improvement plan was implemented after the initial incident, as there were no other residents using a sit-to-stand lift in the facility. This lack of a comprehensive plan contributed to the recurrence of unsafe transfer practices, highlighting the facility's inability to sustain an effective QAA program.
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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