East Carolina Health And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Greenville, North Carolina.
- Location
- 2575 W 5th Street, Greenville, North Carolina 27834
- CMS Provider Number
- 345377
- Inspections on file
- 23
- Latest survey
- March 25, 2026
- Citations (last 12 mo.)
- 10
Citation history
Health deficiencies cited at East Carolina Health And Rehabilitation Center during CMS and state inspections, most recent first.
The facility failed to ensure required RN coverage for 8 consecutive hours on two reviewed days, during which there were more than 70 residents in the building and no RN worked any shift. Review of daily nurse staffing sheets showed blank RN sections on those days, reflecting the absence of RN coverage. The Scheduler stated she completed the sheets from the schedule and left RN spaces blank when no RN was present, and she acknowledged not knowing that blanks were not allowed or what to do when there was no RN coverage. The DON reported being unaware of the lack of RN coverage on those days, and the Administrator stated his expectation that an RN be present in the building for 8 consecutive hours each day.
A resident with dementia, severe behavioral disturbance, and agitation was receiving scheduled oral haloperidol for behaviors, but the facility failed to complete ongoing AIMS assessments after the last one documented several months earlier. The resident’s quarterly MDS reflected cognitive impairment, behavioral symptoms, and antipsychotic use, yet no corresponding quarterly AIMS was found in the EMR. The unit manager and DON reported that AIMS assessments were expected at admission, readmission, with new prescriptions, and quarterly, but acknowledged that required assessments were missed following a change in facility ownership. The pharmacy consultant and Medical Director both indicated AIMS should be performed at least every 6 months for residents on antipsychotics, confirming that the resident’s monitoring was not completed as expected.
A resident with dysphagia, hemiplegia, and hemiparesis following a cerebral infarction was receiving ordered enteral nutrition via feeding tube with documented administration on the MAR, but the quarterly MDS failed to code the presence of a feeding tube or percent of intake by artificial route. The nutrition section of the MDS was completed by the Dietary Manager instead of the MDS Coordinator, and facility staff acknowledged this resulted in erroneous MDS coding that did not accurately reflect the resident’s tube feeding status and intake.
A deficiency occurred when the Pharmacy Consultant did not identify or report missing Abnormal Involuntary Movement Scale (AIMS) assessments for a resident receiving haloperidol for behavioral symptoms. The resident, who had dementia with severe behavioral disturbance and agitation, had an ongoing order for oral haloperidol, but the last documented AIMS assessment in the EMR was several months old, with no subsequent assessments recorded. During monthly drug regimen reviews over multiple months, the Pharmacy Consultant did not document any need for updated AIMS monitoring and stated that he relied on physician and psychiatric notes for side effects and left AIMS assessment decisions to the treating physician.
A resident with ESRD on hemodialysis, chronic respiratory failure, COPD, and moderate protein-calorie malnutrition had multiple ordered medications, including phosphate binders, Carvedilol, and Sertraline. Review of MARs showed that these medications were repeatedly not administered when the resident was out of the building for dialysis, and they were not given upon return. The care plan did not address medication administration on dialysis days or medication availability. The dialysis dietician/NP reported uncontrolled phosphorus levels and believed the facility was not giving the phosphate binder as ordered, while the unit manager acknowledged that medications were routinely held during dialysis days without notifying the Medical Director or on-call provider, contrary to the DON’s stated expectations. The Medical Director confirmed he had not been informed of the missed doses and that medication times could have been adjusted.
Three highly dependent residents with significant mobility and self-care limitations had room call lights that did not illuminate in the hallway when activated, and each was instead provided with a handheld bell. One cognitively intact resident reported her call light had not worked for about a month, stated she had informed staff, and said maintenance told her a part was needed but did not return; another moderately cognitively impaired resident reported her call light had not worked properly for weeks and that a maintenance worker said he would address it later. Observations confirmed the malfunctioning call lights, and review of records showed no work orders for these repairs, while the Maintenance Director acknowledged repeated problems with bulbs and panels and a lack of documentation. Multiple staff, including CNAs, a nurse, the Unit Manager, the DON, and the Administrator, reported they were unaware of the non-functioning call lights and described inconsistent practices for reporting and documenting maintenance issues.
The facility failed to ensure daily nurse staffing sheets were complete and accurate on numerous days, with required entries for total numbers of RNs, LPNs, NAs, total hours worked for evening and night shifts, and resident census left blank. The Scheduler, who was responsible for completing these sheets, reported that she used the schedule to fill them out but frequently stopped to manage staff call-outs and then forgot to finish the forms, and she was unaware that no blanks were permitted. The DON and Administrator both stated that the Scheduler was responsible for the staffing sheets and acknowledged that the forms were expected to include complete staffing and census information for each shift.
A resident who was fully dependent on staff for transfers sustained a fractured humerus when a mechanical lift sling strap broke during a transfer, causing the resident to be lowered to the floor and strike her head and shoulder. Staff reported no visible defects in the sling prior to use, and the resident was hospitalized for evaluation and treatment before returning to the facility.
Two residents developed pressure sores that were not promptly reported to a physician, resulting in delayed treatment orders and incomplete documentation. Nursing staff initiated wound care without physician consultation, and facility protocols requiring physician notification for new pressure sores were not followed. The Wound Physician was only made aware of the wounds during routine rounds, rather than at the time of discovery.
Two residents experienced deficiencies in pressure ulcer care due to delayed reporting, lack of timely communication among nursing staff and the Wound Physician, and failure to promptly implement and document treatment orders. In one case, a pressure sore was not reported until it was unstageable, and diagnostic studies ordered for a non-healing wound were not completed in a timely manner. In another case, a sacral wound was not properly documented or treated for several days, and a change in wound care orders for a heel injury was not transcribed. Additionally, an air mattress was repeatedly set incorrectly for a resident's weight, compromising pressure relief.
A facility failed to involve a resident, who was cognitively intact and had multiple diagnoses, in the development of his person-centered care plan. Despite the expectation for a care planning meeting within 21 days of admission, neither the resident nor his representative were invited to participate. Interviews confirmed the absence of a scheduled meeting, highlighting a lapse in the facility's procedures.
The facility failed to complete a quarterly MDS assessment within 14 days following the ARD for a resident. The assessment remained in progress due to staffing challenges, as confirmed by MDS Nurses. The Administrator acknowledged that assessments should follow the RAI manual's schedule.
The facility inaccurately coded MDS assessments for three residents, leading to discrepancies in their medical records. One resident was incorrectly marked as receiving antipsychotic medication, another was not coded for hospice services despite being admitted to hospice, and a third was wrongly coded as having a pressure ulcer instead of a surgical wound. These errors were due to improper validation of assessment data by MDS nurses.
The facility failed to develop comprehensive care plans for three residents, including one with verbal behavioral symptoms, another prescribed antipsychotic medication, and a third with a surgical wound. Staff interviews revealed that expected care plans were not implemented, leading to deficiencies in addressing the residents' specific needs.
A nurse failed to properly store a bolus enteral feeding syringe after administering medication through a gastrostomy tube to a resident. The nurse did not separate the syringe parts to dry, instead placing the wet syringe back into a storage bag. The DON confirmed that the syringe should have been separated to prevent bacterial growth.
The facility failed to implement Enhanced Barrier Precautions (EBP) when a nurse, a wound nurse, and a wound physician did not wear gowns while providing care to two residents requiring EBP due to indwelling devices and wounds. The staff were unaware of the EBP requirements, despite being trained upon hire, and the facility did not use signage to indicate residents needing EBP.
The facility did not follow its infection control policy, failing to ensure staff received training on Enhanced Barrier Precautions (EBP). The Wound Care Nurse, employed since May 2024, was not trained on EBP and was unaware of its use. The DON could not confirm the nurse's training and could not locate the records, as the SDC responsible for training was no longer employed. The Administrator was unaware of the missing records.
A resident admitted with essential hypertension and dysphagia did not have a comprehensive care plan developed or implemented within the required timeframe. The MDS nurse confirmed the oversight, attributing it to the previous MDS nurse's departure around the time of admission. The DON and Administrator were unaware of the missing care plan, citing communication issues due to the resident's transfer and staff changes.
The facility failed to analyze and address the causes of a resident's multiple falls, leading to an impacted arm fracture, and did not ensure adequate supervision for a paraplegic resident during care, resulting in a fall and injury.
A facility failed to provide appropriate care for a resident with a feeding tube, leading to poor hygiene and a malfunctioning tube. Despite documentation indicating that care was provided, staff could not recall specifics, and an emergency room physician found the site to be unclean and leaking gastric contents.
The facility failed to follow physician orders and proper procedures for administering and documenting narcotic pain medications for three residents. An LPN repeatedly removed narcotics from the medication cart outside prescribed parameters and failed to document the administration, leading to discrepancies between the Controlled Drug Receipt/Record/Disposition form and the MAR.
The facility failed to document the administration of narcotic medication in the MAR for three residents. Multiple doses of narcotics were removed from the medication cart by various staff members, but there was no corresponding documentation on the MAR. The staff involved admitted to either forgetting to document or being bad at documentation. The DON confirmed the discrepancies.
The facility's Quality Assessment and Assurance Committee failed to maintain procedures and monitor interventions, resulting in repeated deficiencies in supervision to prevent accidents, hospice services, and pharmacy services. Issues included not analyzing falls, improper management of narcotic medications, and poor communication with hospice services, leading to multiple incidents of harm to residents.
The facility failed to protect residents' rights to be free from potential diversion of narcotics, involving two residents. Discrepancies in the administration records for Dilaudid and Oxycodone, signed out by an LPN but not documented, raised concerns about potential misuse. Despite staff concerns, the DON and ADON did not suspect drug diversion, as the narcotics were accounted for on the medication cart. The facility's Medical Director and Pharmacist expressed concerns about the potential effects of undocumented administration of narcotics.
The facility failed to communicate and coordinate with hospice services regarding a resident who sustained a dislocated finger. Despite the resident's severe cognitive impairment and behavioral issues, the facility did not document or address the deformity, which was first noted by hospice staff. The lack of communication led to a delay in identifying and addressing the dislocation, resulting in inadequate care.
Failure to Provide Required Daily RN Coverage
Penalty
Summary
The facility failed to provide required RN coverage for 8 consecutive hours on 2 of 142 days reviewed, specifically on 12/28/25 and 1/24/26, despite having daily censuses of 85 and 77 residents, respectively. Review of daily nurse staffing sheets from 11/1/25 through 3/22/26 showed that on those two days there was no RN working any shift, and the RN sections on the staffing sheets were left blank. The Scheduler reported that she completed the daily nurse staffing sheets based on the schedule and, when there was no RN coverage, she left the RN spaces blank, acknowledging that there was no RN coverage on those dates and that she was unaware that blank spaces were not permitted or what steps to take when there was no RN coverage. The DON stated she was unaware there was no RN coverage on those two days and affirmed that there should be an RN in the building for 8 consecutive hours daily, while the Administrator stated his expectation that the facility have an RN in the building for 8 consecutive hours.
Failure to Complete Ongoing AIMS Assessments for Resident on Antipsychotic Medication
Penalty
Summary
The deficiency involves the facility’s failure to provide ongoing Abnormal Involuntary Movement Scale (AIMS) assessments for a resident receiving antipsychotic medication. The resident was admitted with dementia with severe behavioral disturbance and agitation and had a physician’s order for haloperidol lactate 2 mg/ml, 0.5 ml by mouth twice daily for behaviors. Review of the electronic medical record showed the last AIMS assessment was dated 7/29/25, with no subsequent AIMS assessments found. The resident’s quarterly MDS documented cognitive impairment, behavioral symptoms, and use of antipsychotic medication, but there was no corresponding quarterly AIMS assessment in the record. Facility staff interviews confirmed that required AIMS assessments were not completed as expected. The Unit Manager stated that when new ownership took over in November 2025, some assessments were not scheduled and acknowledged that AIMS assessments should be done on admission, readmission, and quarterly, and that this resident’s quarterly AIMS was missed. The DON similarly stated that AIMS assessments were expected at admission, readmission, with new prescriptions, and quarterly, and that unit managers were responsible for completing them. The Pharmacy Consultant stated AIMS should be done at the start of antipsychotic therapy and again at 6 months if no dose changes occurred, and the Medical Director stated AIMS should be completed at least every 6 months, noting that a recent hospitalization might have interfered with timing but that the 6‑month AIMS should still have been completed. The Administrator stated he expected all assessments needed for antipsychotic medications, including AIMS, to be completed timely and reviewed as necessary.
Inaccurate MDS Coding for Tube-Fed Resident
Penalty
Summary
The facility failed to ensure an accurate Minimum Data Set (MDS) assessment for one resident when it did not code the presence of a feeding tube or the percent of intake by artificial route. The resident had a history of dysphagia, hemiplegia, and hemiparesis following a cerebral infarction and had physician orders for enteral nutrition via feeding tube at 60 ml per hour from 6 p.m. to 6 a.m., with 200 ml water flushes every four hours. Review of the Medication Administration Record for the month showed the ordered tube feeding and water flushes were administered as ordered. However, the quarterly MDS assessment did not reflect that the resident had a feeding tube or any intake by artificial route. During interviews, the Regional MDS Consultant reported that the Dietary Manager, rather than the MDS Coordinator, had completed the nutrition section of the MDS, and acknowledged that the MDS coding indicating the resident did not have a feeding tube and lacked intake by artificial route was an error. The Administrator also acknowledged that the MDS assessments should have been coded accurately to reflect the feeding tube and the amount of intake by artificial route.
Pharmacy Consultant Failed to Identify Missing AIMS Monitoring for Antipsychotic Therapy
Penalty
Summary
A deficiency occurred when the facility’s Pharmacy Consultant failed to identify and report irregularities related to required monitoring for an antipsychotic medication during monthly drug regimen reviews. Resident #3, admitted with dementia with severe behavioral disturbance and agitation, had a physician’s order dated 4/21/25 for haloperidol lactate 2 mg/ml, 0.5 ml by mouth twice daily for behaviors. Review of the resident’s electronic medical record showed the last Abnormal Involuntary Movement Scale (AIMS) assessment was dated 7/29/25, with no subsequent AIMS assessments documented after that date. Despite this, the Pharmacy Consultant’s monthly drug regimen reviews dated 10/10/25 and pharmacy reports from November 2025 through February 2026 contained no documentation or recommendations indicating the need for updated AIMS assessments. During an interview, the Pharmacy Consultant stated that AIMS assessments should be completed at the start of antipsychotic therapy and, if no dose changes occur, again at six months. He explained that his reviews focused on physician and psychiatric progress notes for medication-related side effects and that if no issues were noted, he did not make recommendations. He further stated that he left AIMS assessment decisions to the treating physician, resulting in the omission of identifying and reporting the lack of current AIMS assessments for Resident #3 while the resident continued on haloperidol.
Failure to Administer Ordered Medications for Dialysis Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure medications were administered in accordance with physician orders for a resident with ESRD on hemodialysis, chronic respiratory failure, COPD, and moderate protein-calorie malnutrition. The resident’s care plan addressed ESRD, fluid volume management, medication administration as ordered, monitoring vital signs, and diet, and was later revised for ADL assistance, but did not include interventions for medication availability, administration on dialysis days, or medication refusals. Physician orders included Sevelamer (later changed to Sevelamer HCl and then to Velphoro) as phosphate binders, Carvedilol for blood pressure/heart failure, and Sertraline for depression/anxiety. Review of the MARs showed multiple dates on which Sevelamer, Sertraline, and Carvedilol were not administered because the resident was out of the facility or at dialysis at the scheduled administration times. The Dialysis Dietician/Nurse Practitioner reported that the resident’s phosphorus levels were not controlled and believed the facility was not administering the phosphate binder as ordered, noting that the resident did not take medications at the dialysis center and that the medication should have been given with meals or snacks upon return to the facility. She stated the resident’s phosphorus level was 6.5 and that his phosphorus had been well controlled before coming to this facility. The DON stated that when medications are held or not available, nurses should call the on-call provider for direction, but the Nurse Unit Manager acknowledged that medications were held when the resident was out for dialysis, were not given upon return, and that staff did not contact the Medical Director or on-call provider when medications were held. The Nurse Unit Manager also stated that a scheduled afternoon dose of Carvedilol was held every Monday, Wednesday, and Friday during dialysis. The Medical Director stated he had not been informed of missed medications, that his expectation was to be contacted when medications were missed due to the resident being out of the building, and that medication times could have been adjusted so they were not scheduled during dialysis.
Failure to Maintain Functioning Call Light System for Multiple Dependent Residents
Penalty
Summary
Surveyors identified that the facility failed to ensure the resident call light system was functioning properly for three residents whose call systems did not illuminate in the hallway when activated. Maintenance purchase records showed light bulbs were ordered in early February with a noted delivery date in February, but the Maintenance Director later clarified the shipment was actually delayed until mid-March. Work orders from January through March contained no entries for call light repairs for these three residents, and the Maintenance Director acknowledged he had no documentation of the dates and times he worked on the call lights and stated he should have kept a record. One resident with inflammatory and immune myopathies, generalized weakness, and significant dependence on staff for most ADLs, including toileting, transfers, and bathing, reported that her call light had not lit up outside her door for about a month. She stated she informed her nurse aide and nurse, and that maintenance told her a part had to be ordered but never returned to fix it; she was given a handheld bell by the Activities Director. During observation, pressing her call light did not illuminate the hallway light, and a handheld bell was seen in her room. The Activities Director reported learning of this issue during a Resident Council meeting, confirmed the call light was not working when she checked it, and stated she verbally notified maintenance and provided the resident with a bell. Two additional residents, both with generalized weakness, mobility impairments, and high dependence on staff for toileting, transfers, and bathing, also had non-functioning call lights that did not illuminate in the hallway when tested, and handheld bells were observed in their rooms. One of these residents, who was moderately cognitively impaired, stated her call light had not worked properly for a few weeks, reported she told a nurse aide, and that a maintenance staff member told her he would get to it later. The other resident was severely cognitively impaired and not interviewable. The nurse aides, nurse, Unit Manager, DON, and Administrator all stated they were unaware that these residents’ call lights were not working, and staff described varying expectations for reporting repairs, including verbal reports to maintenance, use of a maintenance communication book, and use of a web-based building management system, but there was no documented follow-through for these specific call light issues.
Incomplete and Inaccurate Daily Nurse Staffing Sheets Across Multiple Dates
Penalty
Summary
The deficiency involves the facility’s failure to ensure that daily nurse staffing sheets were complete and accurate for 36 of 53 days reviewed between 12/1/25 and 3/22/26. Record review showed that on multiple specific dates, the sections for total numbers of staff by discipline (RN, LPN, NA) and total hours worked for each discipline on the evening (3:00 pm–11:00 pm) and night (11:00 pm–7:00 am) shifts were left blank. On several of these dates, the resident census was also left blank. These omissions occurred repeatedly across many days in December, February, and March. The incomplete documentation was identified through review of the facility’s daily nurse staffing sheets for the listed dates. For each of those days, the forms lacked required entries for staffing totals and hours worked for evening and night shifts, and on some days, the census field was not completed. The report specifies that this pattern of missing information affected a substantial portion of the review period, indicating that the required daily posting and documentation of staffing levels and census were not consistently recorded as required on the forms. Interviews with facility staff further clarified how these omissions occurred. The Scheduler reported that she used the work schedule to complete the daily nurse staffing sheets but would stop and start this task while addressing staff call-outs and searching for coverage, and then forgot to return to complete the forms for the affected dates. She also stated she was unaware that there could be no blank spaces on the daily nurse staffing sheets. The DON stated that the Scheduler was responsible for completing the daily nurse staffing sheets and that she was unaware they were not fully filled out, and confirmed that the sheets should include total staff numbers and hours by discipline and shift, as well as the census. The Administrator similarly stated that the Scheduler was supposed to complete the daily nurse staffing sheets and that his expectation was that they be completed correctly.
Mechanical Lift Sling Failure During Resident Transfer
Penalty
Summary
A deficiency occurred when a resident, who was totally dependent on staff for transfers and had a history of stroke and chronic pain, was being transferred using a mechanical lift. During the transfer, one of the four straps on the lift sling broke at the seam where it joined the body of the sling. Both nurse aides assisting with the transfer reported that they had not noticed any issues with the sling prior to use and confirmed that the correct size sling was being used. As a result of the strap failure, the resident was lowered to the floor, hitting her head and left shoulder on the bed rail during the process. The resident was subsequently sent to the hospital for evaluation, where she was found to have sustained a left humerus fracture. Hospital records indicated that the resident was on anticoagulant medication and was already receiving multiple medications for chronic pain. Imaging confirmed the fracture, and the resident's arm was immobilized with a sling. She was discharged back to the facility in stable condition after assessment and treatment. Interviews with staff and a representative from the lift manufacturer revealed that the cause of the sling failure could not be definitively determined without examining the sling, but possibilities included normal wear from use and laundering or a manufacturing defect. The facility's Director of Nursing and Administrator confirmed that the sling was not old and that the resident's weight did not exceed the sling's capacity. Prior to the incident, there was no indication that the sling was in disrepair, and staff had not identified any visible defects.
Failure to Notify Physician of New Pressure Sores
Penalty
Summary
The facility failed to notify physicians in a timely manner when two residents developed pressure sores. In the first case, a resident with multiple comorbidities, including cellulitis, lymphedema, and chronic kidney disease, developed a sacral pressure sore that was first identified by the Wound Care Nurse. The nurse did not immediately notify the physician or enter treatment orders into the electronic record, instead applying skin prep and later Santyl without physician consultation. The physician was not notified until several days later during routine rounds, at which point a more comprehensive treatment plan was initiated. In the second case, another resident with a history of diabetes, hypertension, and stroke returned from a hospital stay and was found to have an open area on the sacrum and a deep tissue injury to the right heel. Documentation was incomplete regarding the sacral wound, and there was no evidence that the physician was notified at the time of discovery. The Wound Care Nurse began treatment for the heel injury but did not notify the physician about the pressure sores. A one-time dressing order was obtained for the sacral wound, but there was no further documentation of physician notification or ongoing treatment orders until the resident was seen by the Wound Physician several days later, at which point a stage 4 pressure sore was identified. Interviews with nursing staff and the DON revealed that facility protocols required nurses to notify physicians and obtain orders for new pressure sores, but these protocols were not followed. The Wound Care Nurse and other staff members did not consistently communicate the presence of new wounds to the physician, and documentation was lacking. The Wound Physician confirmed that she was not made aware of the wounds until her scheduled visits, and the DON acknowledged that nurses should have contacted the physician and obtained appropriate orders when new pressure sores were identified.
Failure to Ensure Timely Pressure Ulcer Care, Communication, and Equipment Settings
Penalty
Summary
The facility failed to provide appropriate pressure ulcer care and prevent new ulcers from developing for two residents. In one case, a resident with multiple comorbidities, including cellulitis, lymphedema, and chronic kidney disease, developed a sacral pressure sore that was not reported by nurse aides to a nurse until it was already unstageable. The wound was first identified by the Wound Care Nurse, who did not immediately notify the Wound Physician or enter treatment orders into the electronic record. As a result, there was a delay in initiating appropriate wound care, and the primary care nurses were unaware of the wound or any treatment orders during weekends. The Wound Physician was not consulted at the time of initial discovery, and the treatment plan was not implemented until several days later. Additionally, when the wound failed to heal, further diagnostic studies ordered by the Wound Physician, such as lab work and x-rays, were not completed in a timely manner due to a lack of communication and oversight, resulting in a prolonged period before the underlying infection and other complications were identified. In another instance, a second resident returned from hospitalization and was found to have an open area on the sacrum, but the initial assessment lacked detailed documentation. The Wound Care Nurse did not observe the sacral wound during her assessment, and there was a delay in obtaining and documenting treatment orders. A one-time dressing order was obtained, but no ongoing treatment plan was established or documented for several days. Communication lapses between nursing staff, the Wound Care Nurse, and the Wound Physician led to the wound not being properly addressed until it was identified as a Stage 4 pressure sore by the Wound Physician. Additionally, a change in the treatment plan for a heel wound was not transcribed into the electronic record, resulting in continued use of an outdated treatment. The facility also failed to ensure that the settings of a pressure-relieving air mattress were correctly adjusted for a resident's weight. The air mattress was observed to be set for a much higher weight than the resident's actual weight on multiple occasions, which could have compromised pressure relief. Staff interviews revealed a lack of clarity regarding responsibility for checking and maintaining correct mattress settings, and the Wound Care Nurse acknowledged that the setting was incorrect and should have been adjusted to match the resident's weight.
Failure to Involve Resident in Care Planning
Penalty
Summary
The facility failed to invite a resident to participate in the development of his person-centered plan of care. This deficiency was identified for a resident who was admitted with diagnoses including non-traumatic brain dysfunction, renal insufficiency, diabetes, and hypertension. Despite being cognitively intact, the resident reported that he had never been invited to participate in the care planning process. The resident's care plan had a goal for discharge to the community, but there was no evidence that the resident or his representative had been involved in its development. Interviews with the resident's representative and the facility's social worker confirmed that no care plan meeting had been held within the expected timeframe of 21 days post-admission. The social worker acknowledged that the resident should have been included in a care plan meeting by a specific date but could not provide evidence of scheduling or invitations. The facility administrator also confirmed the expectation for timely care planning meetings, indicating a lapse in the facility's procedures for involving residents and their representatives in care planning.
Failure to Complete Timely MDS Assessment
Penalty
Summary
The facility failed to complete a quarterly Minimum Data Set (MDS) assessment within 14 days following the Assessment Reference Date (ARD) for one resident. Resident #48, who was admitted to the facility, had an MDS assessment with an ARD of 11/15/24 that remained in progress and was not completed timely. Interviews with MDS Nurses revealed that due to staffing challenges, they were behind in completing the assessment according to the Resident Assessment Instrument (RAI) manual requirements. The Administrator confirmed that MDS assessments should adhere to the RAI manual's schedule.
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 #50 was incorrectly coded as receiving antipsychotic medication, despite the Medication Administration Record (MAR) showing no such medication was administered in November 2024. This error was attributed to MDS nurses pulling answers from previous assessments without proper validation, as confirmed by interviews with MDS Nurse #1 and MDS Nurse #2. The administrator acknowledged that MDS assessments should reflect the resident's current status. Resident #173, who was admitted to hospice on November 26, 2024, was not coded for hospice services in her MDS assessment, despite her face sheet indicating hospice Medicaid as her payor source. MDS Nurse #1 confirmed the oversight, and the administrator reiterated the need for accurate coding. Additionally, Resident #58 was incorrectly coded as having a stage III pressure ulcer, although he only had a surgical wound from an abscess removal. The Wound Care Nurse and MDS Nurse #1 both confirmed the miscoding, and the administrator acknowledged the error, emphasizing the importance of accurate MDS coding.
Failure to Implement Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for three residents, leading to deficiencies in addressing their specific needs. Resident #55, who was admitted with diagnoses including cerebral infarction and cognitive communication deficit, exhibited verbal behavioral symptoms. Despite being referred to psychiatric therapy multiple times, the care plan did not include measures to address these behaviors. The Social Worker acknowledged missing the inclusion of behavioral outbursts in the care plan update, and both the Social Worker and Administrator expected these behaviors to be documented in the care plan. Resident #62, diagnosed with conditions such as hypertension and dementia, was prescribed an antipsychotic medication. However, the care plan did not include information regarding the use of this medication. The Social Worker stated she would only include such information if side effects were exhibited, while the Director of Nursing and Administrator expected the medication to be part of the care plan. Additionally, Resident #58, who had a surgical wound from an abscess removal, did not have a care plan for wound care. The Wound Care Nurse and MDS Nurse were unaware of the absence of a wound care plan, and the Director of Nursing and Administrator confirmed that a care plan should have been implemented upon admission.
Improper Storage of Enteral Feeding Syringe
Penalty
Summary
The facility failed to properly store a bolus enteral feeding syringe used for medication administration through a gastrostomy tube for a resident. During an observation, Nurse #3 was seen administering medication to the resident using a 2-part piston and barrel syringe. After use, the nurse rinsed the syringe with water but did not separate the piston from the barrel to dry. Instead, she reassembled the wet syringe and placed it into a plastic storage bag. In an interview, Nurse #3 admitted to storing the syringe without separating the parts, which is against proper protocol. The Director of Nursing confirmed that the syringe should have been separated to prevent bacterial growth during storage.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement its Enhanced Barrier Precautions (EBP) policy, which is designed to reduce the transmission of multidrug-resistant organisms through the use of gloves and gowns during high-contact resident care activities. This deficiency was observed when Nurse #3, the Wound Nurse, and the Wound Physician did not wear gowns while providing care to two residents, Resident #21 and Resident #58, who required EBP due to their medical conditions involving indwelling devices and wounds, respectively. During a medication administration observation, Nurse #3 entered Resident #21's room to administer medications via a gastrostomy tube without donning a gown, despite the resident being care planned for EBP due to the feeding tube. Nurse #3 was unaware of the requirement to wear a gown for residents with indwelling devices. The Wound Physician confirmed that EBP should have been followed to prevent the transmission of multidrug-resistant organisms. The Director of Nursing (DON) and the Administrator acknowledged that Nurse #3 should have worn a gown, and staff were trained on EBP upon hire. In another instance, the Wound Care Physician and Wound Care Nurse entered Resident #58's room to provide wound care without wearing gowns, despite the resident being on EBP for chronic wound care. Both the Wound Care Physician and the Wound Care Nurse were unaware of the EBP requirement, with the Wound Care Nurse stating she had not been trained on EBP. The DON and the Administrator confirmed that gowns should have been worn during wound care, and staff were educated on EBP upon hire, although the facility did not use EBP signage to indicate which residents required these precautions.
Failure to Train Staff on Enhanced Barrier Precautions
Penalty
Summary
The facility failed to adhere to its infection control policy and procedure by not ensuring that staff received training on Enhanced Barrier Precautions (EBP). The Wound Care Nurse, who had been employed since May 2024, reported not receiving any training on EBP and was unaware of its use within the facility. During an interview, the Director of Nursing (DON) admitted to not knowing whether the Wound Care Nurse had been educated on EBP and was unable to locate the training records, as the Staff Development Coordinator (SDC), who was responsible for the education, was no longer employed at the facility. The Administrator also confirmed that staff were supposed to be trained on EBP upon hiring, but was unaware that the DON did not have access to the training records.
Failure to Develop Comprehensive Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for a resident who was admitted with diagnoses of essential hypertension and dysphagia. Upon review of the resident's medical record, it was found that no comprehensive care plans had been developed or implemented. The MDS nurse confirmed that the resident, who had been in the facility for about six weeks, should have had a care plan completed within the first 21 days after admission. The MDS nurse attributed the oversight to the departure of the previous MDS nurse around the time of the resident's admission. The Director of Nursing (DON) stated that the MDS nurse was responsible for developing care plans, and nurses could add to them if they notified the MDS nurse. The DON was unaware of the missing care plan and believed it was a communication issue due to the resident's transfer from assisted living to long-term care coinciding with the MDS nurse's departure. The Administrator also was not aware of the missing care plan and attributed it to the timing of the MDS nurse's departure on the day of the resident's admission to long-term care.
Failure to Prevent Falls and Ensure Resident Safety
Penalty
Summary
The facility failed to adequately analyze and address the causative factors of Resident #2's falls, leading to multiple incidents and an impacted arm fracture. Resident #2, who had severe cognitive impairment and a history of falls, experienced several falls between January and February 2024. Despite these incidents, there was no documented evaluation by therapy staff or a thorough review of the resident's medications, which included Risperdal and Minipress, both of which could contribute to orthostatic hypotension and falls. The facility's investigation into these falls was insufficient, as it did not result in effective interventions to prevent further falls or address the potential medication side effects contributing to the resident's condition. Resident #2's medical records revealed a series of falls, including an unwitnessed fall on January 11, 2024, where the resident reported that God had told her to walk. Subsequent falls occurred on January 21, January 26, and February 2, 2024, with the latter resulting in hospitalization for recurrent falls, orthostatic hypotension, and bradycardia. Despite these incidents, the facility's interventions remained largely unchanged, focusing on ensuring proper footwear, bed positioning, and nursing rounds without addressing the underlying issues. The resident's medications were not adequately reviewed in relation to her falls, and the Psychiatric Nurse Practitioner and Consultant Pharmacist were not fully aware of the frequency and potential medication-related causes of the falls. Additionally, the facility failed to ensure adequate supervision and safety measures for Resident #1, a paraplegic resident, during care. On February 21, 2024, Resident #1 fell out of bed while being bathed by a Nursing Assistant (NA #1), resulting in a superficial forehead laceration. The incident occurred despite the use of short upper side rails, which were later changed to half rails to aid in bed mobility and positioning. The Director of Nursing (DON) attributed the fall to improper body mechanics and positioning by the nursing assistant, and an in-service training on falls prevention was conducted for the staff. However, the facility's documentation and investigation into the incident were inadequate, as the DON did not document interviews with staff or conduct a thorough review of the events leading to the fall.
Failure to Provide Appropriate Care for Feeding Tube
Penalty
Summary
The facility failed to provide appropriate care for a resident with a feeding tube, leading to a deficiency. Resident #1, who had oropharyngeal dysphagia and a percutaneous gastrostomy tube, was readmitted to the facility after a hospital stay. Upon return, there was no documentation describing the condition of the gastrostomy tube site. Multiple nurses and a medication aide documented that they performed the required cleaning and dressing changes, but none could recall the specifics of the site or the dressing. Additionally, there was a day when the cleaning was not documented at all. The situation escalated when the medication aide noticed an issue with the gastrostomy tube and informed Nurse #2, who then sent Resident #1 to the emergency room. The emergency room physician found that the dressing on the gastrostomy tube was dated 12 days prior and was very unclean, with gastric contents leaking from the site and a ruptured balloon. The physician expressed concerns about the poor hygiene care of the gastrostomy tube site. Interviews with the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) revealed that they believed the staff had completed the required care as documented. However, they did not believe the emergency room physician's description of the gastrostomy tube site. The DON and ADON stated that supplies for dressing changes were readily available and that there was good communication among the staff regarding wound care needs.
Failure to Adhere to Physician Orders and Document Narcotic Administration
Penalty
Summary
The facility failed to adhere to physician orders and proper procedures for administering and documenting narcotic pain medications for three residents. For Resident #6, Nurse #5 repeatedly removed Oxycodone with Acetaminophen from the medication cart outside the prescribed parameters and failed to document the administration on the Medication Administration Record (MAR). Despite the resident's severe cognitive impairment, the Director of Nursing (DON) confirmed that the resident was knowledgeable about his pain medication. However, the DON and Nurse #5 did not follow the physician's orders or document the administration properly, leading to discrepancies between the Controlled Drug Receipt/Record/Disposition form and the MAR. For Resident #7, Nurse #5 removed Hydromorphone (Dilaudid) tablets from the medication cart and failed to document the administration on the MAR. Additionally, a tablet was reported lost on the floor without a corresponding signature from another nurse, violating the facility's procedures for handling controlled substances. Resident #7, who was cognitively intact, stated she would not have taken more than the prescribed dose of Dilaudid, indicating a potential over-administration by Nurse #5. Resident #8 also experienced similar issues, with Nurse #5 removing Oxycodone HCL tablets from the medication cart without a physician's order and failing to document the administration on the MAR. The DON confirmed that the Controlled Drug Receipt/Record/Disposition form should match the MAR and that nurses should follow physician orders. The facility pharmacist and Medical Director both emphasized the need for proper documentation and adherence to physician orders, highlighting the facility's failure to monitor and reconcile controlled medications effectively.
Failure to Document Administration of Narcotic Medication
Penalty
Summary
The facility failed to document the administration of narcotic medication in the medication administration record (MAR) for three residents. For Resident #6, multiple doses of Oxycodone with Acetaminophen were removed from the medication cart by various nurses, but there was no corresponding documentation on the MAR. The nurses involved admitted to either forgetting to document or being bad at documentation. The Director of Nursing (DON) confirmed that the Controlled Drug Receipt/Record/Disposition form should match the MAR for accuracy of documentation. For Resident #7, doses of Hydromorphon were removed from the medication cart by a nurse, but there was no corresponding documentation on the MAR. Additionally, there was a dose documented on the MAR without a corresponding entry on the Controlled Drug Receipt/Record/Disposition form. The nurse involved did not respond to interview requests, and the DON confirmed the discrepancy. For Resident #8, multiple doses of Oxycodone HCL were removed from the medication cart by various staff members, but there was no corresponding documentation on the MAR. The staff members involved admitted to either forgetting to document or making human errors. The DON confirmed that the Controlled Drug Receipt/Record/Disposition form should match the MAR for accuracy of documentation.
Repeated Deficiencies in Supervision, Hospice, and Pharmacy Services
Penalty
Summary
The facility's Quality Assessment and Assurance Committee failed to maintain implemented procedures and monitor interventions following multiple surveys, resulting in repeated deficiencies in supervision to prevent accidents, hospice services, and pharmacy services. Specifically, the facility did not analyze a resident's falls to determine causative factors and implement interventions to reduce the risk of further falls. Additionally, the facility failed to ensure a paraplegic resident did not roll out of bed during care. These issues were observed in multiple surveys, including a failure to repair a loose siderail, ensure a fall mat was in place, and provide supervision to a resident assessed as a supervised smoker. The facility also failed to manage narcotic pain medications properly, including removing medications from the cart without physician orders, not following procedures for disposal of wasted narcotic medication, and lacking effective safeguards to control and reconcile controlled medications. Furthermore, the facility did not communicate and coordinate with hospice services effectively, resulting in a resident sustaining a dislocated finger without proper identification and intervention. These deficiencies were observed across several surveys, indicating a pattern of the facility's inability to sustain an effective Quality Assessment and Assurance Program.
Failure to Protect Residents from Potential Narcotic Diversion
Penalty
Summary
The facility failed to protect residents' rights to be free from potential diversion of narcotics, specifically involving two residents. Resident #7, who was cognitively intact, had an order for Dilaudid 2 mg tablets to be administered every 6 hours as needed for pain. However, documentation revealed discrepancies in the administration of the medication, with multiple doses signed out by Nurse #5 but not recorded on the Medication Administration Record. Resident #7 confirmed she would not have taken the medication in such a short time frame, and the facility's Medical Director expressed concerns about the potential effects of such administration. Nurse #5 admitted to poor documentation practices and did not seek physician approval for administering the medication outside the prescribed parameters. Resident #6, who had severely impaired cognition, had an order for Oxycodone with Acetaminophen 5-325 mg tablets to be administered every 4 hours as needed for severe pain. Similar to Resident #7, there were discrepancies in the administration records, with multiple doses signed out by Nurse #5 but not documented on the Medication Administration Record. Interviews with other staff members revealed concerns about the number of doses removed and the lack of documentation. Despite these concerns, the facility's DON and ADON did not suspect drug diversion, as the narcotics were accounted for on the medication cart. Nurse #5 admitted to administering the medication without proper documentation and without seeking physician approval for deviations from the prescribed order. The facility's failure to monitor and document the administration of narcotic medications accurately led to potential diversion and misuse of residents' medications. The discrepancies in the Controlled Drug Receipt/Record/Disposition forms and the Medication Administration Records for both residents raised concerns about the facility's adherence to its abuse prevention program policies and procedures. The facility's Medical Director and Pharmacist both expressed concerns about the potential effects of the undocumented administration of narcotics, highlighting the need for proper monitoring and documentation to ensure residents' safety and well-being.
Failure to Communicate and Coordinate Care for Hospice Resident
Penalty
Summary
The facility failed to communicate and coordinate with hospice services regarding a resident who sustained a dislocated finger. Resident #3, who had a history of stroke, hemiplegia, hemiparesis, dysphagia, and advanced dementia, was admitted to the facility as a hospice resident. The resident's care plan noted behavioral issues, and a significant change Minimum Data Set assessment indicated severe cognitive impairment. Despite these conditions, the facility did not document or address the deformity of the resident's left index finger, which was first noted by hospice staff on 2/27/24. Hospice Nurse #1, who routinely visited the resident twice per week, observed an open wound and a deformity in the resident's left index finger on 3/28/24. The Director of Nursing (DON) was unaware of the deformity, as there had been no documentation by facility staff. Hospice Nurse #2, who had cared for the resident during Nurse #1's absence, reported no deformity when she last saw the resident on 2/27/24. The facility physician, who was also the medical director, was not informed of the deformity until an x-ray was performed on 3/30/24, revealing a dislocated finger with possible septic arthritis. The facility administrator was also unaware of the dislocation until the x-ray results were obtained. The lack of communication between hospice staff and facility staff led to a delay in identifying and addressing the resident's dislocated finger. The hospice physician decided that no further treatment was necessary, and the facility continued with dressing changes as per the hospice orders. The deficiency highlights a significant lapse in communication and coordination between the facility and hospice services, resulting in inadequate care for the resident.
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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