Guilford Health Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Greensboro, North Carolina.
- Location
- 2041 Willow Road, Greensboro, North Carolina 27406
- CMS Provider Number
- 345460
- Inspections on file
- 29
- Latest survey
- March 18, 2026
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Guilford Health Care Center during CMS and state inspections, most recent first.
Surveyors found that kitchen staff failed to label, date, and properly seal multiple opened food items in the walk-in freezer and refrigerator, including pasta, bread, meat, cheese, and stewed apples, some of which showed frostbite, discoloration, and slimy or mushy appearance. The Dietary Manager acknowledged that open items should be labeled, dated, sealed, and discarded as needed. In addition, walls and ceilings in the dishwashing, steamtable/food line, and food prep areas were observed with black substances and deteriorating sheetrock and plaster around AC vents, and staff confirmed that these high surfaces were not being cleaned and had not been repaired.
A resident alleged that staff threw mashed bananas and ice water on her after she had thrown a banana at a nurse. An NP observed the resident wiping water from the floor and was told by the resident that staff were throwing things at her, then notified a nurse manager, who in turn notified the DON and Administrator. The Administrator asked a rehabilitation manager to investigate, and interviews with staff and the resident confirmed that a banana and water had been thrown on the resident, though specific staff were not identified by the resident at that time. Despite facility policy requiring immediate reporting of abuse allegations to the State Survey Agency, law enforcement, and APS, the initial allegation report to the State Survey Agency and law enforcement was not made until two days later, and there was no documentation that APS was notified. The DON later stated she was unaware of the requirement to report the allegation to APS, and leadership acknowledged the allegation was not reported within the required timeframe.
A resident with a history of stroke-related hemiplegia, hemiparesis, and a right tibial fracture was prepared for discharge to an assisted living facility with a goal of returning to the community. The facility’s Discharge Planner altered the resident’s FL2 form by changing ambulatory status and striking three medications, but these changes were not reviewed or signed by a provider. The Assisted Living Executive Director, having previously rescinded a bed offer due to an FL2 indicating non-ambulatory status, refused admission when the corrected but unsigned FL2 was received in the parking lot at the time of attempted admission. As a result, the resident, who reported being able to transfer with a cane and use a wheelchair for distance, was transported back and readmitted to the facility the same day.
Surveyors found that the facility failed to follow its oxygen therapy policy by not posting required "oxygen in use" safety signage for two residents receiving continuous oxygen and by not timely obtaining a provider order for oxygen for one of them. One resident with COPD and respiratory failure had a standing order and documented oxygen use but was repeatedly observed on oxygen without door signage. Another resident with CHF and a tracheostomy was treated for hypoxia and placed on continuous oxygen per a verbal NP order that was not entered into the record for several days, during which the resident continued to receive oxygen without an active order or posted safety signage. Multiple nurses, NAs, the DON, and the Administrator acknowledged that signs and orders should have been in place but could not explain the omissions.
Surveyors observed a nurse leaving a medication cart unlocked and unattended while entering a resident’s room and leaving three unused multiple-dose insulin syringes unsecured on top of the cart. The nurse placed an unlabeled cup containing digoxin, docusate, torsemide, and spironolactone that had been refused by a resident into a cart drawer, and later stored a finasteride tablet that had been dropped on the floor in another unlabeled cup in the same drawer. Additional review of the cart revealed three more unlabeled cups containing multiple unidentified pills, which the nurse attributed in part to medications refused earlier in the day by a resident and not properly wasted. The DON and Administrator stated they expected carts to be locked when unattended, insulin to be secured, and refused or dropped medications to be disposed of rather than stored on the cart.
Multiple residents reported that snacks were not available when requested, leading to feelings of hunger between meals. Staff interviews and observations confirmed that nourishment rooms often lacked snacks, and residents were sometimes told by staff or dietary personnel that no snacks were available. The Dietary Manager indicated that the contracted dietary company did not include snacks in the order guide, resulting in insufficient snack availability despite resident complaints.
Over several months, residents repeatedly voiced grievances during Resident Council meetings regarding issues such as food portions, staff behavior, noise, and environmental cleanliness. These concerns were not consistently documented, addressed, or communicated back to the residents, leading to ongoing frustration among the council members and a lack of resolution for their complaints.
A resident with a PEG tube received multiple crushed medications administered together, rather than individually with required water flushes between each, as ordered by the physician. An agency nurse was unaware of the specific administration protocol, resulting in a medication error rate of 20%, which exceeded the acceptable threshold. The DON confirmed that staff are expected to follow all medication orders.
During a lunch meal service, the facility did not follow the approved menu and diet orders for residents on pureed, renal, and heart healthy diets. Pureed bread was omitted for all residents on pureed diets, and salisbury steak was not provided to those on renal and heart healthy diets as required. Additionally, the recipe for beef stroganoff was not followed, with extra cream sauce added, affecting the nutritional content for residents on regular and mechanical soft diets.
Two cognitively intact residents were unable to access more than $20 per day from their personal funds and could only withdraw money during limited weekday hours, with no access after hours or on weekends. The Business Office Manager confirmed these restrictions, and the new Administrator was unaware of the policy.
A resident with multiple chronic conditions had conflicting code status information between the EMR, which listed Full Code, and a paper binder at the nursing station, which contained a signed DNR form. Staff interviews confirmed reliance on both sources for code status, and the inconsistency was acknowledged by nursing and management.
A comprehensive MDS assessment was not completed within the required timeframe for a resident after admission. The MDS nurse stated the delay was due to a recent increase in new admissions, and the DON was unaware of the specific reason for the late assessment but confirmed it should have been completed within 14 days.
Surveyors identified that the facility failed to accurately code the MDS assessments for two residents: one was discharged to another SNF but was incorrectly coded as discharged to a short-term general hospital, and another, who was exclusively tube-fed due to severe malnutrition and gastrostomy status, was not coded as receiving nutrition via feeding tube on the MDS. Staff interviews confirmed these errors and a lack of cross-departmental review for assessment accuracy.
A resident with an indwelling urinary catheter was repeatedly observed with the catheter drainage bag and tubing lying on the floor, and the tubing was not secured to the leg as required. Staff were aware of the issue but did not resolve it, resulting in a failure to provide appropriate catheter care and prevent infection.
Two residents requiring dialysis did not receive care in accordance with physician orders and facility procedures. One resident with a fluid restriction regularly received more fluids than prescribed due to unclear instructions and poor coordination between nursing and dietary staff. Another resident was not provided a bagged meal or snack on dialysis days because their name was missing from the list used to prepare food for dialysis patients, resulting in the resident going without food during dialysis sessions.
The facility did not consistently develop person-centered baseline care plans or provide summaries to new admissions and their responsible parties within 48 hours. In several cases, essential medical interventions such as urinary catheters and wearable defibrillators were omitted from care plans, and residents or their families were not given or offered copies of the care plan or medication list. Staff interviews revealed confusion about responsibilities, and the DON confirmed that required steps were not being completed.
A resident with severe cognitive impairment was not assessed for safe smoking upon resuming tobacco use after admission. The care plan and medical record lacked documentation of a smoking assessment, and the resident was observed smoking independently without staff supervision. Staff interviews confirmed that required assessments and care planning were not completed when the resident began smoking.
A resident with a gastrostomy tube and severe malnutrition did not receive tube feedings as ordered by the physician. The feeding pump was found off and disconnected, with most of the prescribed formula remaining unused. An agency nurse was unaware of the specific feeding orders and only intermittently administered the feeding, while the resident's private attendant had a history of turning off the pump. The RD confirmed the resident did not receive the required nutrition during the observed period, and the DON acknowledged the nurse's responsibility to ensure the feeding was administered as ordered.
Improper Food Storage and Unsanitary Kitchen Surfaces
Penalty
Summary
The facility failed to properly label, date, seal, and discard food items stored in the main kitchen’s walk-in freezer and refrigerator. During an observation with the Dietary Manager, surveyors found multiple opened, unlabeled, and unsealed items in the walk-in freezer, including cheese ravioli, lasagna pasta sheets, dinner rolls, and hamburger patties, several of which showed signs of frostbite, ice crystal formation, and grayish-brown discoloration. In the walk-in refrigerator, surveyors observed an opened, unlabeled 5-pound bag of shredded parmesan cheese, an opened, unlabeled container of stewed apples with a brownish discolored surface and mushy, slimy fruit, and an opened, unlabeled 1-pound bag of shredded cheese. The Dietary Manager acknowledged that open food items should be labeled and dated daily, sealed when stored, and discarded when needed, and stated that these freezer items needed to be discarded. The facility also failed to maintain clean and intact walls and ceilings in the main kitchen, including the dishwashing, steamtable/food line, and food preparation areas. Surveyors observed black substances on wall and ceiling surfaces in the dishwashing area, as well as on ceiling areas with AC vents over the steamtable/food line and over the food prep table, where the sheetrock and plaster showed deterioration and were no longer supported. Staff interviews revealed that dietary staff had a cleaning schedule and assignments for kitchen cleaning on their shifts but were not responsible for cleaning high walls or ceilings. The Administrator and Maintenance Supervisor confirmed the presence of the black substance and the deteriorated ceiling areas and acknowledged that no work had been performed to remove the black substance or repair the sheetrock or plaster since the issues were identified months earlier.
Failure to Timely Report Allegation of Staff-to-Resident Abuse to Required Agencies
Penalty
Summary
The deficiency involves the facility’s failure to report an allegation of employee-to-resident physical abuse to law enforcement, the State Survey Agency, and Adult Protective Services (APS) within the required time frame. Facility policy required that all alleged violations involving abuse, neglect, exploitation, mistreatment, injuries of unknown source, or misappropriation of property be reported immediately, and no later than 2 hours if the allegation involved abuse or serious bodily injury, or within 24 hours if it did not. The policy also specified that the Administrator or designee must notify the State Survey Agency and other appropriate agencies, and notify law enforcement if the incident was reasonably believed to constitute a crime. On the date of the incident, a nurse practitioner (NP) entered the resident’s room and observed the resident wiping water from the floor with a few ice cubes present. The resident told the NP that staff were throwing things at her, such as mashed bananas. The NP did not observe mashed bananas on the resident or that the resident was wet, but she contacted a nurse manager (Nurse #5) so the DON and Administrator could be notified. Nurse #5 reported that she received a call from the NP stating that the resident had thrown a banana at a nurse and alleged that water was thrown back at her, and Nurse #5 then called the DON and Administrator that afternoon. The Administrator stated he requested the Rehabilitation Manager return to the facility to investigate and later received a call indicating the resident was upset but there was no evidence of abuse at that time. The Rehabilitation Manager reported that he returned to the facility, interviewed staff and the resident, and learned that the resident had thrown a banana at a nurse and that a banana and water were thrown on the resident, though the resident did not identify which staff members. The resident’s family member stated she received a call from the resident the same day reporting that a banana and water were thrown on her, and the family member was told later that an investigation was ongoing. An Initial Allegation Report documenting that staff allegedly threw mashed bananas and ice water on the resident was not completed and faxed to the State Survey Agency until two days after the allegation, and law enforcement was notified the same day the report was completed, not on the day of the allegation. APS notification was not documented in either the Initial Allegation Report or the subsequent Investigation Report. The DON later stated she was unaware that the allegation needed to be reported to APS, and the Divisional Director of Nursing acknowledged that the allegation should have been reported on the day it was made and that the report was not submitted timely.
Failure to Provide Accurate, Provider-Approved FL2 for Discharge to Assisted Living
Penalty
Summary
The facility failed to provide an accurate, provider-approved FL2 form to the assisted living facility to which Resident #117 was being discharged, resulting in the resident being denied admission. Resident #117 had been admitted with a right tibial fracture, hemiplegia and hemiparesis following a cerebral infarction, and difficulty walking. An admission MDS showed she was cognitively intact, required partial assistance for wheelchair mobility, and had a discharge goal of returning to the community. Her care plan identified a need for staff assistance with ADLs, use of a quad cane for transfers, and use of a wheelchair, and included a goal to return to the community with coordination between the facility and her physician regarding discharge plans. An FL2 form signed by Nurse Practitioner (NP) #1 on 5/5/25 documented an assisted living level of care and indicated the resident was semi-ambulatory, with NP #1’s initials noted beside that status. The FL2 also contained three medications that had been struck through, with the medication names rendered unreadable and no indication that NP #1 had approved these changes. The Assisted Living Executive Director later reported that the FL2 he initially received from the facility indicated the resident was non-ambulatory, leading him to rescind the bed offer. The Discharge Planner stated she then corrected the FL2 by changing the ambulatory status from non-ambulatory to semi-ambulatory and striking three medications the resident was no longer prescribed, intending to obtain provider review and signature but acknowledging that this approval had not occurred before discharge. On the morning of 5/13/25, Transportation Aide #1 transported Resident #117 to the assisted living facility for admission. Upon arrival, the Assisted Living Executive Director met them in the parking lot and stated he could not admit the resident because he did not have an approved FL2. Transportation Aide #1 contacted the nursing facility, and another FL2 dated 5/5/25 was sent, showing semi-ambulatory status with the non-ambulatory box whited out and three medications struck through, but without a provider’s signature approving the changes. The Assisted Living Executive Director contacted the Social Work Assistant and advised that he would not admit the resident because the FL2 changes were not provider-approved. NP #1 later confirmed she had signed the original FL2 on 5/5/25 but had not approved any subsequent changes and that her last working day at the facility was 5/5/25. The Administrator acknowledged that the resident should have remained at the facility until an accurate, provider-approved FL2 was provided to the assisted living facility and stated he did not know why this had not been done. Resident #117 reported that she was transported for admission on the morning of 5/13/25, was told in the parking lot that she could not be admitted due to missing paperwork, and was then transported back and readmitted to the nursing facility the same day. She stated that at the time of discharge she was able to transfer from wheelchair to bed using a cane and used a wheelchair for longer distances. The Social Work Assistant and Discharge Planner both confirmed that an amended FL2 was sent while the resident was still in the transportation van at the assisted living facility, but that the Assisted Living Executive Director refused admission because the changes lacked provider approval. The resident remained at the nursing facility until 5/17/25, when she chose to discharge home.
Failure to Post Oxygen Safety Signage and Obtain Timely Oxygen Orders
Penalty
Summary
The deficiency involves the facility’s failure to follow its own oxygen therapy policy requiring a provider order for oxygen and the posting of “oxygen in use” safety signage on door frames of rooms where oxygen is being used. The facility allows smoking by residents, staff, and visitors, yet surveyors observed that two residents receiving continuous oxygen therapy did not have cautionary signage posted on their doors. Staff interviews, including with multiple nurses and NAs, confirmed that they were aware of the policy and that signs should be posted, but they could not explain why signs were missing for these residents. One resident with COPD and acute and chronic respiratory failure had a physician’s order dated 7/22/2025 for continuous oxygen at 2 L/min via nasal cannula, and the annual MDS documented oxygen use. On multiple observations over two days, this resident was seen in bed receiving oxygen at 2 L/min without any oxygen-in-use signage on the room door. Several staff members, including nurses and NAs, acknowledged that the facility’s practice is to post oxygen signs for residents on oxygen and that such a sign should have been present, but none could account for the absence of the sign or reported having noticed it was missing. Another resident with a history of CHF and tracheostomy status was treated by an NP for hypoxia when oxygen saturations were reported in the 80s on room air. The NP stated she gave a verbal order on 3/13/2026 for continuous oxygen at 2–5 L/min via trach mask to maintain oxygen saturation at or above 90%, and expected the order to be entered into the medical record. Observations on subsequent days showed this resident receiving oxygen at 2 L/min via trach mask, including while using a wheelchair with a portable tank, but there was no oxygen order documented until 3/16/2026 and no oxygen-in-use signage on the door during those observations. The assigned nurse, the DON, and the Administrator all confirmed there was no oxygen order in the record for this period and no signage posted, and they were unable to explain why the verbal order had not been entered or why the required signs were not in place.
Improper Medication Cart Security and Handling of Refused and Dropped Medications
Penalty
Summary
Surveyors identified a deficiency in the facility’s handling, labeling, and storage of medications on the 100 Hall Bottom medication cart. During continuous observation of a day-shift nurse, the medication cart was found unlocked while the nurse was inside a resident’s room, and the nurse confirmed the cart should have been locked when unattended. The same nurse left three unused multiple-dose insulin syringes in a plastic bag on top of the unattended cart instead of securing them inside the cart. In addition, after a resident refused a prepared dose of digoxin 125 mcg, docusate 100 mg, two torsemide 20 mg tablets, and spironolactone 50 mg, the nurse placed the unlabeled medicine cup containing these medications in the top drawer of the cart with the intention of offering them again. Later, when administering finasteride 5 mg to another resident, the tablet was dropped on the floor; the nurse picked it up, placed it in a medicine cup, and stored it in the medication drawer beside another unlabeled cup of medications, stating she still needed to waste the dropped tablet. Further inspection of the same medication cart with the nurse revealed three additional unlabeled medication cups in the top right drawer: one cup with a single pill, one with five pills of various sizes, shapes, and colors, and one with three pills of various sizes, shapes, and colors. The nurse indicated that one of these cups contained medications left by a previous-shift nurse after a resident refused a 6:00 a.m. dose, and acknowledged that the medications should have been wasted rather than stored on the cart. The previous-shift nurse confirmed that a resident had refused medications and that they should not have been left on the cart. The DON and Administrator both stated they expected staff to keep medication carts locked when unattended, secure insulin syringes inside the cart, and dispose of refused or to-be-wasted medications rather than storing unlabeled medications in the cart.
Failure to Provide Snacks Upon Resident Request
Penalty
Summary
The facility failed to provide snacks when requested for multiple residents, as evidenced by observations, resident and staff interviews, and review of resident council minutes. Cognitively intact residents, as well as one resident with moderate cognitive impairment, reported that snacks were not available throughout the day and that they often felt hungry between meals. Residents stated that when they requested snacks from staff, they were told there were none available or that staff were too busy to retrieve them from the dietary department. On several occasions, residents attempted to obtain snacks themselves from the kitchen but were informed by dietary staff that no snacks were available. Observations confirmed that nourishment rooms on two different halls lacked snacks, with one room containing only a few slices of bread and a bottle of mustard, and the other having only a single container of mandarin oranges in the refrigerator. Resident council meeting minutes from three separate dates documented ongoing concerns about the lack of snack availability. Staff interviews corroborated that snacks were inconsistently provided, with evening snacks sometimes delivered but daytime snacks often unavailable. The Dietary Manager acknowledged being aware of the residents' concerns and stated that the contracted dietary company controlled the food order guide, which did not include snacks. Despite attempts to order additional items, the supply was insufficient to meet residents' needs. The Administrator was aware of the residents' concerns but was not informed that nourishment rooms were lacking snacks.
Failure to Address and Resolve Resident Council Grievances
Penalty
Summary
The facility failed to act upon and resolve grievances reported by the Resident Council over a period of seven consecutive months. Resident Council meeting minutes consistently documented resident grievances, including issues with banking hours, food portion sizes, lack of snacks, staff behavior (such as not knocking on doors and using phones or earbuds), noise levels at night, and environmental cleanliness. Despite these recurring concerns, there was a lack of documented follow-up or resolution for most grievances from month to month. In some cases, only one grievance from a previous month was addressed, while others were left unresolved, and there was no evidence that the facility communicated efforts to address these concerns to the Resident Council. Interviews with residents, the Activities Director, and the Administrator revealed that grievances raised during Resident Council meetings were not consistently documented on grievance forms or formally communicated to department heads for follow-up. The Activities Director admitted to not filling out grievance forms for concerns brought up in Resident Council and not documenting follow-up actions in the meeting minutes. Residents expressed frustration that their repeated complaints were not being addressed or acknowledged by facility leadership or corporate staff. The Administrator, who was new to the position, was unaware of the lack of documentation and follow-up regarding Resident Council grievances.
Medication Error Rate Exceeds 5% Due to Improper PEG Tube Medication Administration
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, as evidenced by 5 medication errors out of 25 opportunities, resulting in a 20% error rate. The deficiency involved a resident with dysphagia and a PEG tube, who had physician orders specifying that the tube should be flushed with water before and after each individual medication. During a medication pass, an agency nurse prepared and administered all of the resident's prescribed tablets together, crushing them and mixing them in water, rather than administering each medication separately with the required water flushes between each one. The nurse was unaware of the specific physician orders requiring individual administration and separate flushes, and there were no orders permitting the medications to be combined. The Director of Nursing confirmed that staff are expected to follow all medication administration orders. These actions led to the facility exceeding the acceptable medication error rate and not adhering to the resident's prescribed medication administration protocol.
Failure to Follow Approved Menus and Diet Orders During Meal Service
Penalty
Summary
The facility failed to follow the approved, dietitian-reviewed menu for multiple residents with specific dietary needs during a lunch meal service. Eleven residents on a pureed diet did not receive pureed bread as required, and instead only received pureed beef stroganoff, pureed noodles, and pureed peas, with no bread substitute provided. Additionally, three residents on a renal diet and fifteen residents on a heart healthy diet were served beef stroganoff instead of the prescribed salisbury steak. The dietary manager confirmed that the extended menu with detailed diet listings was not easily accessible and admitted to forgetting to provide pureed bread and not realizing the need for a different entrée for renal and heart healthy diets. Further, the recipe for beef stroganoff was not followed for fifty-five residents on regular and mechanical soft diets, as the dietary manager added approximately five cups of extra cream sauce to the beef without following the approved recipe. The registered dietitian confirmed that the additional cream sauce increased the fat content of the dish, which was not appropriate for residents on heart healthy diets. These actions resulted in residents not receiving meals that met their prescribed nutritional needs as outlined in the approved menu.
Failure to Provide Residents with Adequate Access to Personal Funds
Penalty
Summary
The facility failed to provide residents with adequate access to their personal fund accounts, as evidenced by the experiences of two cognitively intact residents. Both residents reported that they were only permitted to withdraw $20 per day from their personal funds, and could only access these funds Monday through Friday between 9:00 AM and 3:00 PM. There were no options for residents to access their funds after hours or on weekends, which limited their ability to manage their own finances and make purchases as desired. Interviews with the Business Office Manager confirmed that these restrictions were set by corporate staff, and that requests for amounts over $20 would be fulfilled by check on the following business day. The Administrator, who was new to the position, was unaware of these limitations and had expected residents to have unrestricted access to their funds. The deficiency was identified through staff and resident interviews, and affected at least two residents who were reviewed for management of personal funds.
Inconsistent Documentation of Advance Directive (Code Status)
Penalty
Summary
The facility failed to maintain consistent and accurate documentation of a resident's advance directive (code status) across both the electronic medical record (EMR) and the paper record kept at the nursing station. For one resident with a history of heart failure, renal insufficiency, and respiratory failure, the paper binder at the nursing station contained a signed Do Not Resuscitate (DNR) form, while the EMR and physician orders indicated a Full Code status. The care plan and recent assessments also reflected the Full Code status, despite the presence of the DNR form in the paper record. Interviews with facility staff revealed that both the EMR and the paper binder were used as sources for code status information, and staff expected these sources to match. Nursing staff and management acknowledged the discrepancy when it was brought to their attention, confirming that the two records did not align for this resident. The resident was noted to have moderately impaired cognition at the time of the deficiency.
Failure to Complete Comprehensive MDS Assessment Within Regulatory Timeframe
Penalty
Summary
The facility failed to complete a comprehensive Minimum Data Set (MDS) assessment within the required regulatory timeframe for one resident. The resident was admitted on a specified date, but review of the admission MDS assessment revealed it was still in progress and not completed as of the review date. During interviews, the MDS nurse acknowledged that the assessment was late, attributing the delay to a recent influx of new admissions. The Director of Nursing was unaware of the reason for the delay but confirmed that the assessment should have been completed within 14 days of admission.
Inaccurate MDS Coding for Discharge Location and Feeding Tube Status
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) assessments for two residents in key areas. For one resident, the Discharge Planner documented in the discharge planning note and nursing progress note that the resident was discharged to another skilled nursing facility. However, the MDS assessment was incorrectly coded as a discharge to a short-term general hospital. The Discharge Planner acknowledged the error during an interview, stating that the correct discharge location should have been selected. Additionally, the MDS Nurse reported that she did not review sections of the assessment completed by other departments for accuracy, and the Administrator confirmed that the Discharge Planner was responsible for ensuring the assessment's correctness. For another resident with diagnoses including severe protein-calorie malnutrition, adult failure to thrive, and gastrostomy status, the physician ordered continuous tube feeding via gastrostomy tube. Despite this, the resident's annual MDS did not indicate that nutrition and hydration were provided through a feeding tube. A subsequent MDS Reconciliation Note confirmed that the resident did not eat or drink by mouth and was fed exclusively by tube feeding, highlighting the inaccuracy in the MDS coding.
Failure to Secure Indwelling Catheter and Prevent Tubing from Contacting Floor
Penalty
Summary
A deficiency was identified when a resident with urinary retention, who had an indwelling urinary catheter, was observed with the catheter drainage bag and tubing lying on the floor beside the bed. The resident was cognitively intact and had a physician's order for the catheter. Multiple observations revealed that the catheter tubing was not secured to the resident's leg, and attempts by a nursing assistant to secure the tubing to the bed were unsuccessful, leaving the tubing on the floor. The nursing assistant reported the lack of a secure strap to a nurse, but the issue was not addressed. Interviews with staff confirmed awareness of the problem. The nurse acknowledged being informed about the unsecured catheter but stated she forgot to address it. Both the Director of Nursing and the Administrator confirmed that the catheter bag and tubing should not have been on the floor and that a device should have been used to secure the tubing. These actions and inactions led to the failure to provide appropriate catheter care and to prevent potential infection risks.
Failure to Adhere to Fluid Restrictions and Provide Meals for Dialysis Residents
Penalty
Summary
The facility failed to provide dialysis care and services in accordance with physician orders and resident needs for two residents requiring dialysis. For one resident with end-stage renal disease and a physician-ordered daily fluid restriction of 1200 ml, the order did not specify how much fluid should be provided by dietary services with meals and how much should be given by nursing staff throughout the day. As a result, the resident's fluid intake records showed multiple days where intake exceeded the prescribed limit. Staff interviews revealed inconsistent knowledge and communication regarding the breakdown of fluid allocation between departments, and the Director of Nursing was unaware that nursing staff did not have clear instructions on fluid distribution. Additionally, the same resident's care plan indicated a fluid restriction, and laboratory results showed increased fluid weight gain, suggesting non-adherence to the restriction. Observations confirmed the resident had access to fluids beyond the prescribed amount, and staff reported that the resident would often request and receive additional fluids. The Registered Dietitian was aware of the dietary fluid allocation but did not know if nursing staff were informed of their portion, further highlighting the lack of coordination. For another resident dependent on dialysis, the facility failed to provide a bagged meal or snack on dialysis days. The resident reported not receiving food when going to dialysis and expressed a desire for a meal or snack. Staff interviews and review of the dialysis resident list revealed that this resident was not included on the list used to prepare and distribute food bags, resulting in the omission. The Director of Nursing confirmed that the resident should have received a snack, and the Administrator acknowledged the need for updated communication and documentation regarding new dialysis residents and their dietary needs.
Failure to Develop and Communicate Baseline Care Plans for New Admissions
Penalty
Summary
The facility failed to develop and implement person-centered baseline care plans and provide summaries to residents and/or their responsible parties within 48 hours of admission for multiple new admissions. In several cases, essential medical needs and physician orders were not reflected in the baseline care plans. For example, one resident admitted with urinary retention and an order for an indwelling urinary catheter did not have catheter use documented in the baseline care plan. Another resident with end stage renal disease and a physician order for a wearable defibrillator (LifeVest) did not have this device included in their baseline care plan. Interviews with nursing staff and the Director of Nursing (DON) confirmed that these omissions occurred and that the care plans should have included these critical interventions. Additionally, the facility did not ensure that baseline care plans and medication lists were reviewed with residents or their responsible parties, nor did they provide copies of these documents within the required timeframe. In several instances, there was no documentation that the care plan or medication list was reviewed or provided, even for residents with cognitive impairment or those whose responsible parties were available. Interviews with staff revealed confusion regarding responsibility for reviewing and distributing these documents, with some agency nurses believing it was the facility staff's duty, and facility staff not consistently completing all required sections or providing the necessary information to residents and families. The deficiency was identified for five residents admitted with various diagnoses, including urinary retention, end stage renal disease, intracerebral hemorrhage, and a fracture. In each case, the baseline care plan was either incomplete, missing critical information, or not communicated to the resident or responsible party as required. The DON acknowledged that nurses were not consistently completing all sections of the baseline care plan or ensuring that residents and responsible parties received and reviewed the care plan and medication summary within 48 hours of admission.
Failure to Complete Smoking Assessment for Resident
Penalty
Summary
The facility failed to complete a smoking assessment for a resident who was reviewed for smoking. Upon admission, the resident was documented as not being a smoker and was assessed as severely cognitively impaired, with no tobacco use coded in the Minimum Data Set (MDS) assessment. The resident's care plan did not include any interventions or considerations related to smoking, and there was no evidence in the medical record that a safe smoking assessment had been conducted. Despite this, the resident was later observed smoking independently in the facility's designated smoking area without staff supervision. Interviews with the responsible party and staff revealed that the resident began smoking again several weeks after admission, but no updated assessment or care plan was created to address this change. Facility staff, including the nurse, unit manager, DON, and administrator, confirmed that a smoking assessment should have been completed when the resident resumed smoking, but this was not done.
Failure to Administer Tube Feeding as Ordered
Penalty
Summary
A deficiency occurred when a resident with severe protein-calorie malnutrition, adult failure to thrive, and gastrostomy status did not receive tube feedings as ordered by the physician. The resident's care plan required tube feedings to meet nutritional and hydration needs, with a physician order specifying continuous administration of formula at 65 ml per hour for 19 hours daily via gastrostomy tube. On observation, the feeding pump was not running, and the tubing was not connected to the resident, with 900 ml of formula remaining in the bag that was supposed to start at 6:00 AM. The resident's private attendant was not present at the time of observation. Nurse interviews revealed that the tube feeding was not consistently administered as ordered, with the nurse stating she was unaware of the specific tube feeding orders and had only intermittently started and stopped the feeding based on the resident's and attendant's requests. The Registered Dietitian confirmed that the resident had not received the required amount of formula for the observed period, and noted a history of the private attendant turning off the feeding pump. The DON stated that the nurse should have ensured the tube feeding was running as ordered and acknowledged the history of the attendant interfering with the feeding process.
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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