Graham Healthcare And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Robbinsville, North Carolina.
- Location
- 811 Snowbird Road, Robbinsville, North Carolina 28771
- CMS Provider Number
- 345355
- Inspections on file
- 19
- Latest survey
- March 5, 2026
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Graham Healthcare And Rehabilitation Center during CMS and state inspections, most recent first.
A resident with atrial fibrillation, CHF, and HTN received digoxin and losartan with physician-ordered hold parameters requiring pulse and BP checks, but staff failed to ensure these parameters were correctly transcribed and flagged in the electronic MAR. Digoxin was administered over several months without the hold parameter appearing on the MAR and with many days lacking documented pulse readings in the electronic record. Losartan was given daily without the hold parameter on the MAR and with only two BP readings documented for the month. Several nurses acknowledged that supplemental documentation to prompt vital sign monitoring was not set up, that they often did not document pulse or BP despite administering the medications, and that order entry and confirmation processes were inconsistently and inaccurately completed. The physician expected adherence to hold parameters, while the DON and Administrator were unaware that monitoring and documentation were not occurring.
A resident with dementia and severely impaired decision-making had a MOST form completed by an NP indicating DNR status, comfort measures, conditional use of antibiotics and IV fluids, and no feeding tube, but the form lacked the required signature of the resident or Resident Representative and did not document the name of the individual with whom the orders were discussed. Medical Records, the DON, the Medical Director, and the Administrator all acknowledged that a resident/representative signature is required for the MOST to be valid, yet the form was still processed and filed without this signature, and the SW’s audits focused only on whether a MOST existed rather than whether it was fully executed.
A resident admitted with diabetes and a history of Guillain-Barre Syndrome later had a diagnosis of intellectual disability added by the Medical Director based on family report and prior records, but no Level II PASRR request was submitted. The diagnosis was documented in the medical record and reflected in the facility’s processes, yet the Social Worker lacked a clear system to track PASRR needs or new diagnoses, and the DON acknowledged that the MDS nurse’s communication of new diagnoses should have triggered a PASRR referral. The Medical Director and Administrator both recognized that an intellectual disability diagnosis requires a Level II PASRR, but the evaluation was never initiated.
A consultant pharmacist failed to identify and report missing monitoring documentation for a resident receiving digoxin with a pulse-based hold parameter and losartan with a systolic BP-based hold parameter. Over several months, the MAR showed these medications were administered as ordered, but the electronic record contained many days without documented pulse and only two documented BPs for the month after losartan was started. Monthly drug regimen reviews by the consultant pharmacist did not include any recommendations regarding these omissions. During interviews, pharmacy staff acknowledged that supplementary orders prompting nurses to document pulse and BP had not been entered and that the consultant pharmacist, who was new, did not know how to verify this in the system, while the physician stated she expected notification when hold parameters were not monitored.
The facility failed to update PASARR evaluations for two residents after new mental health diagnoses were made. One resident, initially admitted with PTSD, was later diagnosed with Major Depressive Disorder, but a Level II PASARR was not completed due to a lack of communication between the NP and nursing staff. Another resident, admitted with dementia, was diagnosed with Major Depressive Disorder and anxiety, but a referral for a Level II PASARR was not made. The Social Worker was not informed of these diagnoses, and the NPs responsible had left the facility.
The facility failed to manage expired medications in both medication rooms and the South medication cart. In the North room, expired Normal Saline with Gentamicin and other medications were found. In the South room, an expired bottle of Multi-Vite was discovered. On the South cart, expired Hemorrhoidal suppositories and undated Latanoprost eye drops were noted. Staff interviews revealed a lack of awareness and oversight in checking for expired medications.
The facility failed to implement its infection control policy during meal service and catheter care. Three nurse aides did not perform hand hygiene between resident contacts, and a nurse did not use PPE or sanitize hands during catheter care for a resident with Enhanced Barrier Precautions. The staff acknowledged awareness of the policies but did not consistently follow them.
The facility failed to document education on the benefits and side effects of the COVID-19 vaccine for three residents, two of whom refused the vaccine. The residents, with varying levels of cognitive impairment, either received or refused the vaccine without documented evidence of being informed. The DON and Interim ADON were unable to provide the necessary documentation, and the Interim Administrator expected staff to educate and document the education provided.
A nurse in an LTC facility was observed by two nursing assistants misappropriating a resident's morphine medication. The nurse was seen taking medication from the cart and later drinking a blue liquid, identified as morphine. The incident was reported to the DON, who conducted a drug test on the nurse, resulting in termination after a positive result for morphine. The resident's medication was replaced, and the facility reported the incident to relevant authorities.
Failure to Monitor and Document Vital Signs for Medications With Hold Parameters
Penalty
Summary
The deficiency involves the facility’s failure to monitor and document required vital signs for a resident receiving medications with physician-ordered hold parameters, resulting in a drug regimen that was not shown to be free from unnecessary drugs. The resident had paroxysmal atrial fibrillation, congestive heart failure, and hypertension, and was prescribed digoxin 125 mcg with instructions to hold the dose if the pulse was below 60. Over multiple months, the MAR showed daily administration of digoxin except on days the resident was out of the facility, but the hold parameter was not transcribed onto the MAR and there was no pulse documentation on the MAR. Review of the electronic health record revealed numerous dates across several months with no recorded pulse, despite ongoing administration of digoxin. The resident was also prescribed losartan 100 mg daily with a physician order to hold the medication if systolic blood pressure was less than 110. The MAR documented daily administration of losartan beginning in February, but again, the hold parameter was not transcribed on the MAR and there was no blood pressure documentation on the MAR. The electronic record contained only two blood pressure entries for that month, and the facility could not produce additional blood pressure documentation. Multiple nurses reported that parameters should have been entered into supplemental documentation to flag the need for pulse and blood pressure checks, acknowledged that this was not done, and could not explain why monitoring and documentation were missed. The nurse responsible for entering and confirming orders stated that orders with parameters were not always entered correctly due to lack of staff knowledge and that sometimes the same nurse both entered and confirmed orders. The physician stated she expected her hold-parameter orders to be followed and identified potential adverse effects, while the DON and Administrator both reported they were unaware that the parameter monitoring and documentation were not being carried out.
Failure to Obtain Required Signature on MOST Form for Cognitively Impaired Resident
Penalty
Summary
Facility staff failed to ensure a Medical Orders for Scope of Treatment (MOST) form was properly completed and validated for one resident reviewed for advance directives. The resident, who had dementia and severely impaired cognitive skills for daily decision-making, was rarely or never understood and had both short- and long-term memory problems, and had a designated Resident Representative. A MOST form dated 10/6/25 documented DNR status, comfort measures, antibiotics if indicated, IV fluids for a defined trial period, and no feeding tube. The form stated it had been discussed with and agreed to by an individual with an established relationship with the patient who could reliably convey the patient’s wishes, and it was signed by an NP. However, the form did not identify the name of the individual with whom it was discussed, and the patient or representative signature section at the bottom of the form was blank. Interviews revealed multiple staff were aware that a MOST form must be signed by the resident and/or Resident Representative to be valid, including Medical Records, the Medical Director, the DON, and the Administrator, all of whom confirmed that this resident’s MOST form was not valid due to the missing representative signature. Medical Records staff stated she was responsible for reviewing completed MOST forms for all required dates and signatures before scanning them into the electronic record and placing the hard copy in the code book, and acknowledged she missed that this resident’s form lacked the Resident Representative’s signature. The Social Worker reported she audited MOST forms mainly to see who had a form, and was unsure if an unsigned form was valid. The NP who completed the form stated she was not aware that the resident/representative signature was required, misinterpreting the language above the signature box as making the signature optional, and did not document the name of the person with whom the form was discussed or obtain a witness signature for a telephone review. The Administrator and Medical Director both indicated that, given the resident’s cognitive status, the Resident Representative’s signature was required and that, if completed by phone, the form should document the representative’s name, indicate telephone review, and include two witness signatures.
Failure to Initiate Level II PASRR After New Intellectual Disability Diagnosis
Penalty
Summary
The deficiency involves the facility’s failure to submit a Level II Preadmission Screening and Resident Review (PASRR) evaluation after a resident was diagnosed with an intellectual disability. A Level I PASRR completed in the hospital emergency room listed only diabetes and a history of Guillain-Barre Syndrome. The resident was admitted with these diagnoses, and upon admission the Medical Director completed a history and physical on the same day, adding a new diagnosis of intellectual disability based on information from the resident’s family representative and past medical records. This diagnosis was added to the resident’s diagnosis list in the facility’s medical record, and the resident’s subsequent MDS assessment showed the resident to be cognitively intact. However, there was no evidence in the medical record that a Level II PASRR request was ever submitted following the addition of the intellectual disability diagnosis. Interviews with staff revealed gaps in communication and tracking related to PASRR requirements. The Social Worker stated that hospitals typically completed PASRRs for residents admitted from the hospital and that she completed PASRRs for residents admitted from home, but she could not describe how she tracked PASRRs or how she became aware of new diagnoses. She later acknowledged that the resident had been diagnosed with an intellectual disability months earlier and that a Level II PASRR should have been submitted shortly after that diagnosis was added. The DON explained that new diagnoses were entered by the MDS nurse and then communicated at morning meetings so the Social Worker could initiate PASRRs as needed, and acknowledged that a Level II PASRR should have been completed for this resident but could not explain why it was not. The Medical Director confirmed that she added the intellectual disability diagnosis after reviewing family input and prior records, knew that such a diagnosis required a Level II PASRR, and stated she did not handle PASRR submissions. The Administrator also agreed that a Level II PASRR evaluation should have been submitted once the intellectual disability diagnosis was added.
Consultant Pharmacist Failed to Identify Missing Monitoring for Medications With Hold Parameters
Penalty
Summary
A deficiency occurred when the consultant pharmacist failed to identify and report missing monitoring documentation for a resident receiving medications with hold parameters. The resident was admitted with paroxysmal atrial fibrillation, congestive heart failure, and hypertension, and had a physician’s order for digoxin 125 mcg by mouth in the evening with instructions to hold the dose if the pulse was below 60. The MAR showed digoxin was administered daily over several months, except on two days when the resident was absent, while the electronic health record showed numerous days in October, November, December, January, and February with no documented pulse. Despite this pattern, monthly drug regimen reviews dated in November, December, January, and February contained no recommendations related to digoxin or the lack of pulse documentation. The same resident also had a physician’s order for losartan 100 mg by mouth daily with a hold parameter if the systolic blood pressure was less than 110, and the MAR showed daily administration beginning in February. However, documentation of blood pressures for that month was limited to two dates, and the facility could not produce additional blood pressure records. During interviews, the consultant pharmacist and supervisor consultant pharmacist stated that the facility had not entered supplementary orders prompting nurses to document pulse with digoxin or blood pressure with losartan, and the supervisor explained that the consultant pharmacist was new and did not know how to check this in the system. The consultant pharmacist did not identify the lack of monitoring documentation during monthly reviews, while the physician stated she expected the pharmacist to notify the facility when hold parameters were not being monitored, and the administrator reported she was unaware that the consultant pharmacist did not know how to review hold parameter documentation.
Failure to Update PASARR Evaluations for Residents with New Mental Health Diagnoses
Penalty
Summary
The facility failed to submit requests for updated Pre-Admission Screening and Resident Review (PASARR) evaluations for two residents after they were diagnosed with additional mental health conditions. Resident #11, who was admitted with fibromyalgia, osteoarthritis, and PTSD, was later diagnosed with Major Depressive Disorder. Despite this new diagnosis, a Level II PASARR was not completed. The Social Worker, responsible for notifying the State Mental Health Authority, was not informed by nursing of the new diagnosis, and the Nurse Practitioner (NP) who diagnosed the resident did not communicate this to the nursing staff. The NP had since left the facility, and the new Physician Assistant (PA) was unfamiliar with the resident's case. Similarly, Resident #3, admitted with dementia and a history of bipolar disease, was diagnosed with Major Depressive Disorder and anxiety disorder. However, a referral for a Level II PASARR evaluation was not completed. The Social Worker was not notified of these new diagnoses by nursing, and the Psychiatric NP who diagnosed the resident had also left the facility. The new PA was unfamiliar with the resident's case. The Interim Administrator expected that a Level II PASARR would be completed for residents with new mental health diagnoses, but this was not done for either resident.
Expired Medications and Labeling Issues in Medication Rooms and Cart
Penalty
Summary
The facility failed to properly manage and discard expired medications in both the North and South medication rooms, as well as on the South medication cart. In the North medication room, five bags of Normal Saline with Gentamicin, intended for a resident's urinary catheter irrigation, were found with expiration dates ranging from 12/5/24 to 12/17/24, despite being punctured and only viable for 48 hours. Additionally, expired Bisacodyl suppositories and Guaifenesin were found in the same room. Interviews with Nurse #1 and the Consultant Pharmacist revealed a lack of awareness and oversight regarding the expired medications. In the South medication room, an unopened bottle of Multi-Vite with an expiration date of November 2024 was found. Nurse #2 indicated that night shift nurses were responsible for checking for expired medications, but the expired bottle was overlooked. The Nurse Supervisor admitted to checking the medication rooms monthly but failed to notice the expired items. The Director of Nursing (DON) expressed surprise that the expired medications were not identified and removed sooner. On the South medication cart, expired Hemorrhoidal suppositories and an opened bottle of Latanoprost eye drops without an open date were discovered. Nurse #2 acknowledged the oversight, noting that the suppositories were no longer needed and the eye drops were administered only at bedtime. The DON reiterated that supervisors should check stock medications, while nurses were responsible for the medication carts, but was unaware of why the expired medications were still available for use.
Infection Control Deficiencies During Meal Service and Catheter Care
Penalty
Summary
The facility failed to adhere to its infection control policy during meal service in the dining room, as observed with three nurse aides. Nurse Aide #2 was seen touching a resident's hands and hair, then moving to another resident without sanitizing her hands. She also assisted multiple residents with meal setup without changing gloves. Nurse Aide #1 adjusted a resident's clothing protector and served another resident without hand hygiene. Nurse Aide #3 placed gloves in her pocket, washed her hands, then reused the gloves to touch a resident's sandwich. Interviews with the aides revealed they were aware of the hand hygiene policy but failed to consistently follow it. Additionally, the facility's policy for Enhanced Barrier Precautions (EBP) was not implemented correctly by Nurse #1 during urinary catheter care for Resident #4. Despite signage indicating the need for gloves and a gown, Nurse #1 entered the room without a gown, did not perform hand hygiene before donning gloves, and failed to sanitize hands between glove changes. Nurse #1 acknowledged the oversight, attributing it to the resident's agitation and her attempt to expedite care. The Director of Nursing confirmed that the staff should have followed the infection control policies, including hand hygiene and the use of PPE, especially in rooms with EBP signage. The DON stated that Nurse #1 had been educated on these protocols but did not adhere to them during the observed incident.
Lack of Documentation for COVID-19 Vaccine Education
Penalty
Summary
The facility failed to document the education provided to residents regarding the benefits and potential side effects of the COVID-19 vaccine for three residents. Resident #2, who was admitted with severely impaired cognition, received the COVID-19 vaccine, but there was no documentation in the medical record indicating that the resident or their legal representative was informed about the vaccine's benefits and potential side effects. The Interim Assistant Director of Nursing (ADON) and the Director of Nursing (DON) were unable to provide the required documentation when requested. Resident #11, who had moderate cognitive impairment, refused the COVID-19 vaccine, but there was no documented evidence that the resident or their legal representative was educated about the vaccine's benefits and potential side effects. The resident confirmed during an interview that they did not recall receiving such education. The DON acknowledged the lack of documentation regarding the education provided. Similarly, Resident #18, also with moderate cognitive impairment, refused the COVID-19 vaccine without documented evidence of education about the vaccine's benefits and potential side effects. The resident did not recall being educated about the vaccine, and the DON confirmed the absence of documentation. The Interim Administrator stated that staff were expected to educate and document the education provided, but this was not done for these residents.
Misappropriation of Controlled Medications by Nurse
Penalty
Summary
The facility failed to protect a resident's rights to be free from misappropriation of controlled medications. The incident involved a nurse who was observed by two nursing assistants during a night shift. The nurse was seen taking a brown bottle and another bottle of liquid from the medication cart, preparing a syringe with a clear liquid, and claiming he was going to administer it to the resident. The nursing assistants observed suspicious behavior, including the nurse drinking a blue liquid from a medication cup, which was later identified as morphine. The nursing assistants reported their observations to the Director of Nursing (DON) after being unsure of what to do. The DON conducted a urine drug test on the nurse, which returned positive for morphine and other substances. The nurse was subsequently terminated from his position. The resident's missing morphine medication was replaced at the facility's expense, and the physician confirmed that the resident did not suffer adverse effects from missing a dose of pain medication. The facility's policy on abuse, neglect, or misappropriation of resident property was not effectively enforced, leading to the misappropriation of the resident's medication. The incident was reported to the appropriate authorities, including the North Carolina Board of Nursing and the Drug Enforcement Agency. The facility conducted a thorough investigation, which substantiated the allegations against the nurse.
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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