Hibriten Mountain Nursing And Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Lenoir, North Carolina.
- Location
- 2030 Harper Avenue Nw, Lenoir, North Carolina 28645
- CMS Provider Number
- 345329
- Inspections on file
- 30
- Latest survey
- February 26, 2026
- Citations (last 12 mo.)
- 15 (1 serious)
Citation history
Health deficiencies cited at Hibriten Mountain Nursing And Rehabilitation during CMS and state inspections, most recent first.
Surveyors found systemic failures in controlled substance management, including a case where oxycodone doses were signed out for a resident after the resident had been sent to the hospital, with no corresponding MAR documentation and an unreadable second signature. In addition, two residents did not have their prescribed oxycodone available, leading multiple nurses and a Unit Manager to repeatedly borrow oxycodone from other residents’ supplies over several days, despite the absence of a borrowing policy and without consistent DON notification or documentation of replacement. Monthly pharmacy audits over several months documented missing nurse signatures on shift‑change counts, discrepancies between controlled substance records and MARs for opioids and lorazepam, incorrect card counts, early PRN administrations, and wasting without a second nurse witness, while facility leadership reported being unaware of these specific controlled substance issues and did not fully reconcile or act on the audit findings.
A resident who was cognitively intact had a personal bottle of calcium carbonate (Tums) in her room, brought in by family so she could take it for heartburn as needed, despite having no physician order for the medication and no documented self-administration assessment. Surveyors observed the bottle, partially full, on the bed and over-bed table when the resident was not present. A nurse reported she was unaware the medication was in the room, confirmed there was no self-administration order, and stated the resident sometimes became lethargic due to her medications. The DON also confirmed there was no order for the antacid or for self-administration, indicating the resident had unsupervised access to a medication without clinical evaluation or authorization.
Surveyors found that the facility failed to ensure DNR and advance directive information was accurately completed and consistent across records for three residents. One resident had a DNR order and EMR banner indicating DNR, but no corresponding DNR form in the code status notebook that staff rely on during emergencies. Another resident had a DNR physician order in the EMR while the care plan and a physician progress note documented Full Code, and there was no code status documentation in the notebook. A third resident had hospital and facility physician documentation indicating DNR, while the MOST and advance directive discussion forms signed by the responsible party indicated CPR and lacked a physician signature; these forms were placed in the code notebook instead of the physician’s folder for review, creating conflicting code status information.
A resident was admitted with a completed Level I PASRR that instructed the facility to resubmit for a Level II PASRR if a new mental health diagnosis or significant change in condition occurred. After admission, the resident exhibited a history of hallucinations, paranoia, and prior aggressive behavior in the hospital, was treated with multiple antipsychotics and anti-anxiety medications, and was later diagnosed in the facility with paranoid schizophrenia. The MDS reflected schizophrenia and psychotropic use but still indicated only a Level I PASRR. Although the MDS Coordinator recognized the new diagnosis and reported it to a former SW, neither the MDS Coordinator nor the SW had access to submit Level II PASRR requests, and the Assistant Business Office Manager reported never receiving a referral request. No Level II PASRR evaluation was requested for the resident despite the documented new mental health diagnosis and the Administrator’s understanding that such referrals should be made when new mental health diagnoses are identified.
A resident with dementia, Parkinson's disease, DM, bowel and bladder incontinence, and multiple ADL dependencies had only a single nutrition-focused care plan entry despite MDS and CAA findings identifying needs in cognition, self-care and mobility, urinary incontinence, psychosocial well-being, activities, falls, nutritional status, pressure ulcer risk, and psychotropic drug use. The MDS Coordinator confirmed that no other care plan areas were present, stated she had completed a comprehensive care plan, and attributed its absence to possible loss during recent computer upgrades, while acknowledging the requirement to complete a comprehensive care plan within 21 days of admission.
A resident admitted with urinary retention had an indwelling urinary catheter documented on the MDS and supported by physician orders for catheter maintenance, including catheter and bag changes, catheter care every shift, use of a stat lock, and placement checks every shift, with daily catheter care recorded on Treatment Administration Records. Despite this, the comprehensive care plan did not include any mention of the urinary catheter. The MDS Coordinator acknowledged the omission and attributed it to issues during an electronic medical record upgrade, while the Administrator stated that care plans are expected to accurately reflect each resident’s clinical condition, medications, and care needs.
A resident with dementia, Parkinson’s disease, DM, and arthritis, who required extensive assistance with ADLs and was at risk for pressure ulcers, did not receive appropriate foot care or podiatry services. The care plan addressed only nutritional issues, and weekly nursing assessments did not document the resident’s increasingly long, thick toenails. The resident was never placed on the podiatry schedule and had not been seen by a podiatrist since admission. During observations, the resident’s toenails were found to be thick, long, jagged, with discoloration of the great toenail, and both the resident and family reported the resident could not care for her own feet. A NA stated she had noticed the long toenails but did not remember reporting it, while the wound nurse and ADON acknowledged the resident had not been referred for podiatry despite her DM.
Surveyors found an open, undated box of DuoNeb inhalation solution on a medication cart, despite manufacturer instructions that vials be used within a set timeframe after opening the foil pouch. A nurse acknowledged that the box should be dated when opened and that unused vials should be discarded after a specified number of days. The DON reported that nurses are expected to check medication carts daily and ensure DuoNeb solutions are dated, with the nurse who opens the box responsible for dating it. The lack of dating on the opened DuoNeb box resulted in a deficiency related to proper labeling and storage of drugs and biologicals.
Staff failed to follow hand hygiene and Enhanced Barrier Precautions policies during suprapubic catheter care for a resident with an indwelling urinary catheter. An aide and a nurse entered the room, donned gloves from the PPE station, but did not wear gowns despite an EBP sign requiring gown and glove use for high-contact care. The aide removed a soiled dressing, changed gloves multiple times without performing hand hygiene between glove changes, and then cleaned the suprapubic site and catheter tubing. The nurse applied a new dressing and washed hands only after glove removal, later stating she had not noticed the EBP sign and did not believe her actions required a gown, while the aide acknowledged she should have worn a gown and performed hand hygiene.
A resident with scheduled and PRN oxycodone orders had two 30‑tablet cards of 5 mg oxycodone delivered from the pharmacy, with the delivery signed for by an RN who reported verifying both cards and then handing them to the nurse assigned to the resident’s medication cart. Review of the controlled drug count sheet for that cart showed no increase in the number of controlled medication cards during the relevant shift, and only one oxycodone card was ever documented on the count sheet. The DON later confirmed that 30 oxycodone tablets for this resident were unaccounted for and that, despite review of pharmacy delivery records and staff interviews, the missing card of controlled medication could not be located or explained.
Surveyors identified a medication error rate of 15.38% during observations, including multiple errors involving two residents. One resident with COPD and moderately impaired cognition was allowed to self-administer a nasal spray and two inhalers without instruction, resulting in extra sprays and puffs beyond ordered doses and no mouth rinse after a steroid inhaler as ordered. In a separate case, a resident with diabetes received Lispro insulin via a prefilled pen that the nurse dialed directly to the ordered dose without priming, contrary to manufacturer instructions requiring a 2-unit prime to expel air and confirm insulin flow. Both nurses later acknowledged they were aware of the correct procedures but failed to follow them.
A housekeeper at an LTC facility misappropriated approximately $4,000 from a resident's bank account by using the resident's debit card to set up a mobile payment account without permission. The resident, who was cognitively intact, discovered the unauthorized transactions after the BOM discussed his overdue bill. Despite reporting the incident to law enforcement, the case was closed due to insufficient evidence.
The facility failed to accurately code MDS assessments for two residents regarding bladder continence. One resident with a stage 4 pressure ulcer and a foley catheter was incorrectly marked as always incontinent, while another resident with paraplegia and a catheter was marked as always continent. Errors were due to unchecked system-generated answers.
A resident with severe cognitive impairment and wandering behaviors ingested wound cleanser, but the care plan was not updated to reflect the risk of ingesting non-food items. Despite the incident being discussed in an interdisciplinary team meeting, the MDS nurse responsible for care plan updates was unaware of the incident, and the care plan remained unchanged.
A medication error occurred when a resident was mistakenly given medications prescribed for another resident due to a distraction during medication pass. The resident, who was cognitively intact and had multiple diagnoses, did not experience adverse effects as the medications were weaker than his prescribed ones. The error was reported to the DON, NP, and MD, who determined it was not significant due to the lack of adverse outcomes.
A resident admitted with pneumonia and other conditions was using supplemental oxygen without a physician's order, and the facility failed to post required oxygen cautionary signage. Staff interviews revealed confusion about responsibilities for obtaining orders and posting signs.
A facility failed to report a misappropriation of a resident's property to the state agency within 24 hours and did not notify APS. The incident involved a resident's bank account being accessed by a former employee through a mobile payment app. The Business Office Manager discovered the issue and informed the Former Administrator, who delayed reporting to the state agency until after a police investigation concluded without charges. The Former Administrator did not report to APS, as the allegation was unsubstantiated based on the police's decision.
A resident with Fredrick's Ataxia fell off the bed during incontinence care due to inadequate assistance, while another resident with Alzheimer's ingested wound cleanser left unattended on a treatment cart. The facility failed to secure hazardous materials and ensure proper supervision, leading to these safety incidents.
A resident with a history of physical behaviors and moderate cognitive impairment did not have a comprehensive care plan addressing their need for 1 on 1 supervision. Despite ongoing supervision for nine weeks, the care plan was not updated to reflect this requirement. Interviews with facility staff, including the MDS Coordinator and DON, confirmed that the resident's behaviors and supervision needs should have been included in the care plan.
A resident admitted for respite services through Hospice was discharged from the facility without proper documentation or reason. Despite being informed of the resident's agitation and having medications sent to manage these behaviors, the facility did not administer the medications as ordered. The DON decided the facility could not provide care due to a lack of staff for one-on-one supervision, and the resident was sent to the hospital. Interviews revealed the resident's behaviors were easily redirected, and the interim Administrator was not fully informed of the situation.
A resident admitted for respite services was sent to the hospital due to agitation, and the facility refused to allow his return, citing inability to manage his care. Despite having orders to administer medications for his behaviors, the facility did not do so and insisted on discharging him. Interviews revealed a lack of communication and understanding of the resident's needs, leading to unnecessary hospitalization and transfer to another facility.
A resident with multiple health conditions did not receive timely incontinence care, resulting in her wetting through her brief and pants. The resident's care plan required peri-care every two hours, but due to the nurse aide's workload, the resident was not attended to until several hours later. The DON emphasized the expectation for regular checks and changes.
The facility failed to follow its Infection Control Policy for Enhanced Barrier Precautions during wound care for two residents. The Wound Nurse did not wear a gown, as required, despite the policy's guidelines for high-contact activities. PPE was not available for one resident, and although it was available for the other, the nurse forgot to don a gown. Interviews revealed the nurse was aware of the requirement but was nervous and forgot.
Systemic Failures in Controlled Substance Accountability and Availability
Penalty
Summary
The facility failed to maintain accurate control, accountability, and reconciliation of controlled substances for multiple residents over several months. One resident with a PRN order for oxycodone 30 mg was sent to the hospital after becoming unresponsive, hypotensive, and hypoxic. After the resident left the facility, two doses of this resident’s oxycodone were signed out on the controlled medication utilization record, including one dose documented by a nurse and another with an unreadable signature and time, even though the resident was no longer in the building. The resident’s MAR showed the last oxycodone dose administered earlier that afternoon, and there was no documentation supporting administration of the two later doses. The facility’s internal investigation could not determine who signed out the second dose, and the nurse identified as signing out at least one dose did not cooperate with inquiries. The facility also failed to ensure that physician‑ordered narcotic pain medications were available and properly supplied for two other residents, leading staff to repeatedly “borrow” controlled substances from other residents’ supplies. One resident with a scheduled oxycodone 15 mg order received doses documented on the MAR using another resident’s oxycodone 15 mg supply over several days, with at least 20 tablets signed out as borrowed by multiple nurses and the Unit Manager. Staff reported that it was common practice to borrow controlled medications when a resident’s supply ran out, often without notifying the DON, and they were unclear how borrowed medications were replaced or reimbursed. The DON acknowledged there was no policy for borrowing controlled substances, stated that nurses were not supposed to borrow medications, and could not produce records showing that the resident’s oxycodone had been reordered, delivered, or that the supplying resident had been reimbursed. Another resident with an order for oxycodone 10 mg PRN for pain had doses administered using two 5 mg tablets taken from a different resident’s oxycodone 5 mg supply, with documentation on that resident’s controlled substance accountability record indicating at least 12 tablets were borrowed by several nurses and the Unit Manager. The Unit Manager stated that the resident’s own oxycodone supply had been exhausted and that borrowing from another resident was common when medications ran out, despite the availability of a backup oxycodone 5 mg supply and without obtaining DON approval. The DON again reported no policy for borrowing controlled substances, was unaware of the frequency of borrowing, and could not provide documentation that the resident’s oxycodone had been reordered or that the supplying resident’s medication had been replaced. Over a five‑month period, monthly pharmacy storage audits conducted by the Consultant Pharmacist repeatedly identified systemic deficiencies in controlled substance management. These included missing nurse signatures on shift‑change controlled substance counts on multiple medication carts and halls, discrepancies between the number of doses signed out on controlled substance accountability records and the doses documented as administered on MARs for several residents receiving opioids and lorazepam, incorrect or unclear card counts, PRN controlled substances administered earlier than ordered intervals, and controlled substances wasted without a second nurse witness signature. The Consultant Pharmacist documented these findings on multiple monthly audit forms, noting ongoing issues with controlled substance documentation and reconciliation. The DON stated she was not aware of the specific controlled substance concerns cited in the audits, had not reviewed the monthly storage audit reports, did not perform full reconciliations of controlled substance records against MARs, and was unaware that nurses were wasting controlled substances without a second signature. The Administrator reported she was not aware of the audit‑identified controlled substance issues and stated that any such concerns should have been addressed by nursing leadership.
Failure to Assess and Authorize Resident Self-Administration of Antacid Medication
Penalty
Summary
The deficiency involves the facility’s failure to assess a resident for the ability to self-administer medications and to ensure appropriate physician orders were in place. The resident was admitted on an unspecified date and had a quarterly MDS assessment indicating she was cognitively intact. Review of the resident’s physician orders showed no order for calcium carbonate (Tums), and review of the medical record revealed no self-administration assessment. Despite this, surveyors observed a bottle of Tums tablets, approximately one-quarter full, on the resident’s bed and later on her over-bed table when the resident was not present in the room. During an interview, the resident stated that her family had brought the Tums because she needed them when she had heartburn, that she did not take them often, but wanted to be able to take them when needed, and she could not recall when she last took them. A nurse later stated she was unaware the resident kept Tums in her room, confirmed there was no order for the resident to self-administer medications, and expressed that the resident would not be safe to self-administer due to periods of lethargy related to her medications. The DON also confirmed there was no order for the resident to self-administer and no existing order for an antacid for heartburn, demonstrating that the resident had unsupervised access to a medication without assessment or physician authorization.
Inconsistent and Incomplete DNR and Advance Directive Documentation
Penalty
Summary
The deficiency involves the facility’s failure to properly complete, maintain, and reconcile advance directive and DNR documentation for multiple residents. For one resident admitted with a physician order for Do Not Resuscitate (DNR), the EMR banner and physician orders reflected a DNR status, but there was no corresponding DNR form in the advanced directives notebook at the nurse’s station. Nursing staff reported that, in an emergency, they would rely on the EMR and the advanced directives notebook to determine code status. The DON confirmed that a DNR form should have been present in the notebook for this resident and stated that the Social Worker was responsible for completing advance directive forms at admission and auditing the notebook, but the prior Social Worker had left and it was unclear whether the family had been consulted or a DNR form completed. Another resident had conflicting code status information across the medical record. The EMR contained a physician order for DNR, but the resident’s care plan documented Full Code status, and a physician progress note also listed the advanced directive status as Full Code Blue. The quarterly MDS indicated this resident was cognitively intact. The code status notebook at the nursing desk contained no advanced directive information for this resident. The Administrator and DON both stated that advanced directive information should match throughout the record and that the Social Worker was responsible for initiating and auditing this paperwork, but the Social Worker had recently resigned. Staff interviews showed that nurses and the Unit Manager relied on either the EMR profile page or the code status notebook, depending on accessibility, and expected these sources to match. A third resident had discrepancies between hospital documentation, physician orders, and paper advance directive forms. The hospital discharge summary and a physician order in the facility EMR both indicated a DNR status, and a physician progress note documented “Do Not Attempt Resuscitation (DNR/no CPR).” However, the MOST form in the code book, signed by the resident’s Responsible Party (RP), indicated a preference for attempted CPR, and the Advanced Directive Discussion Document also indicated CPR. The MOST form lacked a physician signature. The resident, who had moderately impaired cognition per the admission MDS, stated that he and his RP had decided he would not want CPR. The Director of Sales and Marketing/admission Coordinator, who had been completing advance directive paperwork in the absence of a Social Worker, reported that the RP had chosen CPR on both forms and that she placed these documents in the code notebook rather than in the physician’s folder for review and signature. The DON verified that the physician’s DNR order did not match the paper forms in the code notebook and acknowledged the missing physician signature on the MOST form.
Failure to Initiate Level II PASRR After New Schizophrenia Diagnosis
Penalty
Summary
The deficiency involves the facility’s failure to submit a required Level II Preadmission Screening and Resident Review (PASRR) referral for a resident who developed and was documented with a new mental health diagnosis after admission. A Level I PASRR was completed prior to admission with instructions to resubmit paperwork for a Level II PASRR if a new mental health diagnosis was suspected or if there was a significant change in condition. The resident’s hospital discharge summary documented hallucinations, delusions, and treatment with multiple antipsychotic and anti-anxiety medications, but did not list a diagnosis of schizophrenia. Upon admission, the resident’s EMR showed no mental health diagnoses, and the admission MDS later reflected that the resident had schizophrenia and had received antipsychotics, anti-anxiety medications, and anticonvulsants during the look-back period, while still indicating only a Level I PASRR. Subsequent psychiatric evaluation documented that the resident had a history of military service, long-standing mental illness related to war experiences, hallucinations, paranoia, and an incident in the hospital where a nurse was physically injured. The psychiatric NP confirmed that the resident reported a history of paranoid schizophrenia and that this history was verified with a family member. The resident was diagnosed in the facility’s EMR with paranoid schizophrenia on a specific date, but there was no evidence in the record that a Level II PASRR referral was submitted following this new diagnosis, despite the prior Level I PASRR instructions and the resident’s mental health history and current psychotropic medication regimen. Interviews with facility staff revealed communication and process failures that contributed to the lack of a Level II PASRR referral. The MDS Coordinator stated she identified the paranoid schizophrenia diagnosis from a psychiatric note and reported it to the former social worker, who no longer worked at the facility, but could not recall when this occurred. The MDS Coordinator and the former social worker did not have access to submit Level II PASRR requests and were reliant on the Assistant Business Office Manager, who reported she had not received any information or request regarding this resident and typically received such information during morning clinical meetings. The Administrator acknowledged that a Level II PASRR should be completed upon admission of a resident with a mental health diagnosis or when a new mental health diagnosis or change in condition occurs, and stated that the resident should have had a Level II PASRR referral when the paranoid schizophrenia diagnosis was added, but could not explain why the referral was not submitted.
Failure to Maintain Comprehensive Person-Centered Care Plan After Admission
Penalty
Summary
Surveyors identified that the facility failed to develop an individualized, person-centered comprehensive care plan for one resident. The resident was admitted with dementia, Parkinson's disease, DM, hypertension, and arthritis, and the admission MDS showed moderately impaired cognition, need for supervision or assistance with eating, bed mobility, oral hygiene, toileting, transfers, bathing, and dressing, as well as bowel and bladder incontinence. The MDS also documented that the resident was on a therapeutic diet, at risk for pressure ulcer development with no current wounds, had no pain or weight loss, had received antipsychotic, antianxiety, and hypoglycemic medications, and was planning to discharge back to the community. Review of the resident’s comprehensive care plan showed only one entry, developed by the RD, addressing potential nutritional problems, with no other care areas included despite multiple triggered CAAs. The CAAs completed by the MDS Coordinator identified needs in cognitive loss/dementia, functional abilities for self-care and mobility, urinary incontinence, psychosocial well-being, activities, falls, nutritional status, pressure ulcer injury, and psychotropic drug use, but these were not reflected in the written care plan. During interview, the MDS Coordinator confirmed that the only care plan entry present was for nutrition, stated she remembered completing the comprehensive care plan, and acknowledged awareness that a comprehensive care plan must be developed within 21 days of admission. She reported that there had been two recent computer upgrades and thought something may have happened to the resident’s care plan during those updates. The Administrator stated she expected all residents to have an accurate and complete comprehensive care plan reflecting their clinical condition, medications, and care needs.
Failure to Include Indwelling Urinary Catheter in Comprehensive Care Plan
Penalty
Summary
The facility failed to develop a comprehensive care plan addressing an indwelling urinary catheter for one resident, as required to be completed within 7 days of the comprehensive assessment and prepared by an interdisciplinary team. The resident was admitted with urinary retention and had an indwelling urinary catheter documented on the admission MDS assessment. Physician orders dated 06/23/25 directed that the urinary catheter be maintained with catheter changes as needed, catheter bag changes as needed, catheter care every shift and as needed, placement of a stat lock to secure the catheter, and verification of catheter placement every shift. Treatment Administration Records for June and July 2025 showed the resident had a urinary catheter and received daily catheter care. However, review of the comprehensive care plan dated 07/03/25 revealed no mention of the urinary catheter. During an interview, the MDS Coordinator acknowledged that the urinary catheter was not included on the care plan and stated that at the time of the resident’s admission the facility was undergoing a company change and electronic medical record upgrade, and it was possible the system did not accept her care plan input. The Administrator stated she expected all residents to have an accurate and complete comprehensive care plan reflecting their clinical condition, medications, and care needs.
Failure to Provide Foot Care and Arrange Podiatry for Diabetic Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate foot care and arrange podiatry services for a resident with dementia, Parkinson’s disease, and diabetes mellitus. On admission, the nursing assessment did not note any toenail issues, and the admission MDS documented moderately impaired cognition, need for assistance with mobility, toileting, transfers, bathing, and dressing, as well as diagnoses of Parkinson’s disease, dementia, DM, and arthritis, and risk for pressure ulcer development. The resident’s care plan, developed by the RD, addressed only potential nutritional problems and did not include any other care areas. Weekly nursing assessments over several months contained no notation that the resident’s toenails were long, thick, or needed trimming. Review of the podiatry clinic schedule and EMR showed the resident was not scheduled for, nor seen by, a podiatrist since admission. During observations, surveyors noted the resident had thick, long, jagged toenails on both feet, with a brownish discoloration at the base of the left great toenail extending toward the middle of the nail. The resident stated her toenails looked “nasty,” that she could not bend down to care for her feet, and that her daughter had trimmed her toenails before admission. The wound nurse acknowledged she did not notice the resident’s toenails and had not requested that she be added to the podiatry list. The ADON stated the resident should be seen by a podiatrist because she was diabetic and confirmed that, although responsible for adding residents to the podiatry schedule in the absence of a Social Worker, she had not referred this resident since admission. A NA who frequently provided showers reported noticing that the resident’s toenails were very long and needed trimming but could not recall if she reported this to a nurse. The resident’s family member confirmed the resident had been unable to care for her feet for a long time and that she previously kept the toenails trimmed due to the resident’s diabetes.
Failure to Date Opened DuoNeb Inhalation Solution on Medication Cart
Penalty
Summary
Surveyors identified a deficiency in the facility’s medication labeling and storage practices involving DuoNeb inhalation solution on one of three medication carts reviewed (the C and D cart). Manufacturer guidelines for DuoNeb require that, after opening the foil pouch, individual vials be used within 14 days. During an observation of the C and D medication cart with a nurse, surveyors found an open, undated box of DuoNeb solutions stored in the cart drawer and available for use, with a delivery date on the box of 12/23/25. The nurse interviewed stated that the box should be dated when opened and that vials not used within 7 days should be discarded. In a separate interview, the DON stated that nurses are expected to check medication carts daily and that ensuring DuoNeb solutions are dated is part of those daily checks, and that the nurse who opens the box is expected to date it. This failure to date the opened box of DuoNeb solution, despite manufacturer instructions and facility expectations for daily cart checks and dating by the opening nurse, led to the cited deficiency in ensuring drugs and biologicals are labeled in accordance with accepted professional principles.
Failure to Follow Hand Hygiene and Enhanced Barrier Precautions During Catheter Care
Penalty
Summary
The deficiency involves failure to follow the facility’s Infection Control and Hand Hygiene policies during suprapubic catheter care for Resident #26. The facility’s Hand Hygiene policy required staff to perform hand hygiene before donning gloves and immediately after removing them, and the Enhanced Barrier Precautions (EBP) policy required use of gown and gloves for high-contact resident care activities, including providing hygiene to residents with indwelling urinary catheters. An EBP sign specifying the need for gown and gloves was posted on the resident’s door. During an observation of suprapubic catheter care, Nurse Aide #1 and Nurse #4 entered the resident’s room, removed gloves from the PPE tower, and applied gloves without donning gowns, despite the posted EBP sign. While providing suprapubic catheter care, Nurse Aide #1 removed a dirty dressing from the suprapubic site, then removed her dirty gloves and applied clean gloves without performing hand hygiene. She then cleaned the suprapubic site and catheter tubing, removed her dirty gloves again, and applied clean gloves without using hand sanitizer between glove changes. Nurse #4 applied a dressing to the suprapubic site, then removed her gloves and washed her hands. In interviews, Nurse Aide #1 acknowledged the resident was on enhanced barrier precautions, stated she should have worn a gown, and admitted she did not wash her hands between glove changes. Nurse #4 stated she did not initially know the resident’s precaution status, did not pay attention to the EBP sign on the door, and believed she had not performed any care that warranted wearing a gown. The DON confirmed that both staff should have worn gowns for EBP and that hand hygiene should have been performed between glove changes.
Unaccounted Controlled Medication Following Pharmacy Delivery
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident’s narcotic medications from misappropriation. A resident admitted on an unspecified date had physician orders for oxycodone 5 mg tablets, one tablet every 12 hours for pain, and an additional 5 mg oxycodone order every 6 hours as needed for breakthrough pain, which was later discontinued. Pharmacy records showed that two 30‑tablet cards (total 60 tablets) of 5 mg oxycodone immediate‑release were delivered for this resident on 09/04/25 at 10:38 PM, with the delivery receipt signed by a nurse (Nurse #3). The medications were supposed to be handled as controlled substances and documented on controlled drug count sheets kept with the medication cart. Nurse #3 reported that opioid or narcotic medications arrived in sealed purple bags and that the receiving nurse was responsible for verifying the medication and quantity before signing the delivery sheet. She verified that she signed for the resident’s oxycodone delivery on 09/04/25 and stated she distinctly remembered two 30‑tablet cards being delivered and that she verified the count and medication before signing. She further stated that after signing, she gave the resident’s oxycodone to the nurse assigned to the resident (Nurse #4) so that two separate controlled drug count sheets could be completed, one for each card. However, only one controlled drug count sheet was ultimately completed, and Nurse #3 stated she did not know what happened to the resident’s oxycodone and that it never made it to the medication cart as expected. Review of the controlled drug count sheet for the relevant medication cart from 08/31/25 through 09/06/25 showed that at the 3:00 PM shift change on 09/04/25 there were 41 cards of medications on the cart, verified by the oncoming nurse, Nurse #4. At 11:00 PM, Nurse #4 again signed that there were 41 cards, with no additions or subtractions documented during her shift, and the two oxycodone cards delivered for the resident on 09/04/25 were not added to the controlled drug count sheet. The DON later confirmed awareness that 30 oxycodone tablets were missing for this resident and that the discrepancy came to light when a nurse attempted to refill the oxycodone and the pharmacy reported it was too early because 60 tablets had already been delivered and at least 30 should still have been available. The DON reported that a search of the medication cart did not locate the additional card and that, despite interviews and review of records, it could not be determined whether the pharmacy failed to deliver both cards or whether one card went missing between pharmacy delivery and placement on the medication cart. The former Administrator similarly recalled that the investigation focused on the nurse assigned to the cart at the time but that the missing card of oxycodone could not be accounted for.
Medication Administration Errors and Failure to Follow Inhaler and Insulin Pen Instructions
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with surveyors identifying 4 errors out of 26 opportunities (15.38%) during medication administration observations. For one resident with COPD and moderately impaired cognition, physician orders included a daily fluticasone nasal spray, a twice-daily budesonide/glycopyrrolate/formoterol steroid inhaler with instructions to rinse the mouth after use, and albuterol inhaler four times daily. During a medication pass, a nurse handed the resident the nasal spray and two inhalers and allowed her to self-administer without providing instructions. The resident then administered two sprays of the nasal spray in each nostril and three puffs of albuterol, exceeding the ordered doses, and after using the steroid inhaler, the nurse did not instruct her to rinse her mouth with water as ordered. The nurse later acknowledged awareness that the resident had taken too many puffs of the nasal and albuterol inhalers and that the steroid inhaler required a post-use mouth rinse to prevent oral thrush but stated he did not think about it at the time. In a separate incident, another resident with diabetes mellitus had a physician order for 8 units of Lispro insulin subcutaneously before meals when blood sugar was between 301 and 350. During an observed insulin administration using a prefilled insulin pen, a nurse removed the Lispro pen from the medication cart, dialed the dose directly to 8 units, and administered the insulin without priming the pen as required by the manufacturer's instructions. The manufacturer’s directions specified priming the pen each time by dialing 2 units, pressing the injection button to expel air and confirm insulin flow, and checking for a drop of insulin at the needle tip, repeating if necessary. When questioned, the nurse stated she followed the five rights of medication administration but then acknowledged she was aware of the need to prime the pen and realized she had forgotten to perform this step. The consultant pharmacist and DON confirmed that residents should be instructed on inhaler use, including mouth rinsing after steroid inhalers, and that insulin pens must be primed to remove air and ensure full dosing.
Misappropriation of Resident's Funds by Housekeeper
Penalty
Summary
The facility failed to protect a resident's right to be free from misappropriation of property when a housekeeper used the resident's debit card without permission. The housekeeper set up a mobile payment application account on his phone and transferred approximately $4,000 from the resident's bank account over several months. The resident, who was cognitively intact, was unaware of these transactions and only discovered the issue when the Business Office Manager (BOM) discussed his overdue bill with him. The resident had initially given his debit card to the housekeeper to purchase a drink from a vending machine, which was the only time he recalled the housekeeper having access to his card. Upon realizing his card was missing, the resident, with the help of the BOM, contacted the bank and discovered the unauthorized transactions. The BOM reviewed the bank records and identified the transactions linked to the housekeeper's mobile payment account, prompting a report to law enforcement. Despite the facility's efforts to report the crime and assist the resident, the police investigation did not result in charges due to insufficient evidence. The mobile payment application company claimed to have no record of the housekeeper's account, and the case was eventually closed. The resident expressed distress over the loss of his funds and the breach of trust by someone he relied on.
Removal Plan
- The Business Office Manager obtained bank statements for Resident #70 and identified unauthorized transfers by Housekeeper #1.
- The Business Office Manager, with consent from Resident #70, requested a direct deposit for Resident #70's Social Security checks into his RFMS account.
- Resident #70's Social Security checks were direct deposited into his resident trust account managed by the facility.
- The Executive Director reported the misappropriation of Resident #70's property to local law enforcement.
- The Executive Director filed the initial allegation to the State agency.
- Resident #70 was seen by the psychiatric nurse practitioner and continued to be followed by psychiatric services.
- Resident #70's liability with a total balance of $628 has been written off.
- The Business Office Manager audited the current Resident Financial Management System (RFMS) to ensure no unauthorized activity had occurred.
- The Business Office Manager reconciled the asset account to the resident trust fund liability account monthly.
- A Resident Trust fund statement is mailed to the patient and/or Guardian/Responsible Party quarterly.
- The Social Worker interviewed alert and oriented residents to ensure no employee had asked any resident for money or use of their debit, credit, EBT, and/or Ucard.
- The Executive Director and/or Director of Nursing re-educated current staff on the Abuse Policy with emphasis on misappropriation of resident property.
- Education included the use of a sign-out sheet for snacks and drinks purchases.
- Staff were educated to not accept debit cards from residents for vending machine purchases.
- The Executive Director verbally educated residents that the use of debit cards by staff is not allowed for vending machine purchases.
- Residents are made aware upon admission and throughout their stay of having the option to secure valuables.
- The Maintenance Director handles the request of a resident's need for a lock on their nightstand.
- All residents/responsible parties were offered a RMFS account upon admission.
- The Executive Director held an ADHOC Quality Assurance Performance Improvement meeting.
- The Executive Director and/or Director of Nursing to complete quality monitoring of five residents weekly for twelve weeks.
- The Business Office Manager reconciled the asset account to the resident trust fund liability account monthly.
- The results of the quality monitoring will be brought to the Quality Assurance Performance Improvement meeting monthly for 3 months.
- The Executive Director is responsible for overseeing the plan of correction.
Inaccurate MDS Coding for Bladder Continence
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) assessments for two residents regarding bladder continence. Resident #74, who was admitted with a stage 4 pressure ulcer and had a foley catheter in place, was incorrectly marked as always incontinent of bladder on the MDS assessment. The MDS Coordinator acknowledged that the assessment should have been marked as 'Not Rated' due to the presence of the indwelling catheter. The error was attributed to the system-generated answers that were not properly checked. Similarly, Resident #35, who had paraplegia and neuromuscular dysfunction of the bladder, was also inaccurately coded. Despite having an indwelling catheter since before admission and throughout the lookback period, the resident was marked as always continent of bladder. MDS Nurse #1 admitted to missing the correction in the system-generated answers, which should have been marked as 'Not Rated'. The Director of Nursing confirmed that the resident's bladder continence should have been coded accurately to reflect her condition.
Failure to Update Care Plan After Resident Ingests Non-Food Item
Penalty
Summary
The facility failed to update a resident's care plan after an incident where the resident ingested wound cleanser. The resident, who was admitted with diagnoses including Alzheimer's disease, anxiety, major depressive disorder, and adult failure to thrive, was noted to have severe cognitive impairment and daily wandering behaviors. An incident report dated March 11, 2024, documented that the resident ingested an unknown amount of wound cleanser, and although the resident was assessed and monitored with no negative side effects observed, the care plan was not updated to address the potential for ingesting non-food items. Interviews with facility staff revealed a lack of communication and follow-through regarding the incident. MDS Nurse #1, who was responsible for updating care plans, was unaware of the incident and stated that such behavior should have been included in the care plan. MDS Nurse #2, who was the MDS nurse at the time of the incident, also reported being unaware of the incident and did not recall any discussion of it in the interdisciplinary team meeting. The Director of Nursing confirmed that the incident was discussed in a team meeting and that the care plan should have been updated immediately, but it was not. This oversight resulted in the resident's care plan not reflecting the risk of ingesting non-food items, despite the known wandering behaviors and cognitive impairment.
Medication Error Involving Incorrect Administration
Penalty
Summary
The facility failed to ensure the correct medications were administered to the correct resident, resulting in a medication error involving Resident #80. Resident #80, who was cognitively intact and had diagnoses including peripheral vascular disease, neuropathy, and necrotizing fasciitis, was mistakenly given Baclofen and Norco, medications prescribed for another resident, Resident #59. This error occurred during a medication pass by Nurse #2, who was distracted by another resident while preparing the medication. Upon realizing the mistake, Nurse #2 informed Resident #80 of the error and monitored his vital signs before contacting the on-call provider. The provider instructed Nurse #2 to continue monitoring Resident #80's level of consciousness and breathing. Resident #80 reported that the medication error did not significantly affect him, as the medications he received were weaker than his prescribed pain medication, and he did not experience any breakthrough pain. The Director of Nursing (DON) and the Nurse Practitioner (NP) were notified of the incident. Both the NP and the Medical Director (MD) assessed the situation and concluded that the medication error was not significant due to the lack of adverse effects on Resident #80. The DON confirmed that Nurse #2 followed the necessary steps after the error, including notifying the appropriate parties and monitoring the resident's condition.
Failure to Obtain Oxygen Order and Post Signage
Penalty
Summary
The facility failed to obtain a physician's order for the use of supplemental oxygen for a resident who was admitted with diagnoses including left lower lobe pneumonia, sepsis, and pleural effusion. Despite the resident being cognitively intact and continuously using oxygen at 1.5 liters via nasal cannula since admission, there was no documented order for this treatment in the resident's medical record or Medication Administration Record (MAR) for several months. This oversight was confirmed during an interview with a nurse who regularly checked the resident's oxygen saturation but was unaware of the lack of a formal order. Additionally, the facility did not post the required oxygen cautionary signage on or near the resident's door, as observed on multiple occasions. Interviews with staff, including a nurse aide and the Director of Nursing (DON), revealed a lack of clarity regarding responsibility for posting such signage. The DON acknowledged that the nurse who initiated the oxygen should have obtained an order and posted the cautionary sign, and that department managers should ensure signage is in place during their rounds.
Failure to Timely Report Misappropriation of Resident Property
Penalty
Summary
The facility failed to report an allegation of misappropriation of resident property to the state agency within the required 24-hour timeframe and did not report the incident to Adult Protective Services (APS). The incident involved a resident who had money stolen from their bank account, with transactions traced to a former employee's mobile payment application account. The Business Office Manager (BOM) discovered the issue when the resident mentioned losing their debit card and needing assistance with the bank. Upon reviewing the bank statements, the BOM found multiple unauthorized transactions and informed the Former Administrator, who then filed a police report. The Former Administrator delayed submitting the initial allegation report to the state agency, waiting until the police investigation concluded without charges against the former employee. Consequently, the report was filed 20 days after the facility became aware of the issue, and no report was made to APS. The Former Administrator unsubstantiated the allegation of misappropriation based on the police's decision not to file charges, which contributed to the failure to report the incident to APS.
Safety Lapses Lead to Resident Incidents
Penalty
Summary
The facility failed to provide care in a safe manner when a dependent resident, identified as Resident #57, fell off the bed during incontinence care. Resident #57, who was admitted with Fredrick's Ataxia, required extensive assistance for bed mobility and personal hygiene. On the day of the incident, a nurse aide, NA #2, was providing incontinence care and rolled the resident onto her side. Despite keeping a hand on the resident's hip, the resident continued to roll off the bed and onto the floor. The resident reported ankle pain, and an x-ray was ordered, which showed no fracture. The nurse aide admitted to not reviewing the care plan, which indicated the need for assistance, and relied on the resident's statement that only one person was needed for care. Another incident involved Resident #8, who ingested an unknown amount of wound cleanser left unattended on a treatment cart. Resident #8, diagnosed with Alzheimer's disease and exhibiting wandering behaviors, accessed the wound cleanser from the cart. The ingestion was reported to the nurse, who assessed the resident and contacted poison control. The resident was monitored for adverse effects, but none were observed. The wound cleanser was routinely stored on top of the cart or in a side pocket, rather than being locked away, which allowed the resident to access it. Interviews with staff revealed that the wound cleanser was not typically secured, and the Director of Nursing acknowledged that it should have been locked away. The facility's failure to secure hazardous materials and ensure adequate supervision during care led to these incidents, highlighting lapses in safety protocols and staff adherence to care plans.
Failure to Develop Comprehensive Care Plan for Resident with Behavioral Needs
Penalty
Summary
The facility failed to develop a comprehensive, individualized, and person-centered care plan for a resident with a history of physical behaviors. The resident, who was admitted with diagnoses including cerebral infarction, anxiety disorders, metabolic encephalopathy, and vascular dementia, was observed to have moderate cognitive impairment. Despite the need for 1 on 1 supervision due to physical behaviors towards other residents and staff, the care plan did not address these behaviors. Nursing Assistant #4 reported providing 1 on 1 supervision for the resident for approximately nine weeks, yet the care plan, last reviewed on December 6, 2024, did not reflect this need. Interviews with the MDS Coordinator and the Director of Nursing revealed that the resident's need for 1 on 1 supervision and history of behaviors should have been included in the care plan. The MDS Coordinator acknowledged that changes in a resident's condition, such as the need for 1 on 1 care, should have been discussed and care planned during morning meetings. The Director of Nursing confirmed awareness of the resident's behaviors and the ongoing supervision since July 2024, indicating that the care plan should have been updated to reflect these needs. The Administrator also expected all care plans to be completed accurately, highlighting a lapse in the facility's care planning process.
Failure to Administer Medications and Improper Discharge of Resident
Penalty
Summary
The facility failed to allow a resident with behaviors to remain in the facility and did not provide written documentation stating the reason they could not meet the resident's needs. The resident, admitted for respite services through Hospice, exhibited agitation and attempted to get up from his wheelchair unassisted. Despite being informed of the resident's behaviors and having medications sent with him to manage these behaviors, the facility did not administer the medications as ordered by Hospice. The Director of Nursing (DON) communicated with the Hospice nurse about the resident's agitation and received verbal orders to administer medications to calm the resident. However, the medications were not administered, and the facility decided they could not provide care for the resident, citing a lack of staff for one-on-one supervision. The DON informed the on-call Hospice nurse that the resident could not stay at the facility, and the resident was subsequently sent to the hospital. Interviews with the Hospice nurse, on-call Hospice nurse, and Hospital Nurse Practitioner revealed that the resident's behaviors were easily redirected and that the facility was aware of the resident's needs prior to admission. The interim Administrator was not fully informed of the situation, including the availability of medications to manage the resident's agitation. The failure to administer the prescribed medications and the decision to discharge the resident without adequate documentation or reason led to the deficiency.
Facility Fails to Allow Resident Return After Hospitalization
Penalty
Summary
The facility failed to permit a resident to return after hospitalization, violating the bed-hold policy. The resident, admitted for respite services through Hospice, was sent to the hospital due to agitation and behaviors that the facility claimed they could not manage. Despite having orders to administer medications to address the resident's agitation, the facility did not administer these medications and instead decided to discharge the resident to the hospital without attempting to manage the behaviors as per the orders. The Director of Nursing (DON) and the interim Administrator were involved in the decision to not allow the resident to return, citing the facility's inability to provide the necessary care. The DON did not administer the prescribed medications and did not allow the Hospice nurse to do so either. The resident was described as being easily redirected and not aggressive, yet the facility insisted on sending him to the hospital and refused his return, even after the hospital confirmed that the resident was stable and could be managed with the prescribed medications. Interviews with various staff members, including the Hospice nurse, hospital nurse practitioner, and facility nurses, revealed a lack of communication and understanding of the resident's needs and the available resources to manage his care. The facility's decision to not allow the resident to return was made without fully utilizing the prescribed interventions or considering the hospital's assessment that the resident was stable and manageable. This resulted in the resident spending unnecessary time in the hospital and being transferred to another facility the following day.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to provide timely incontinence care to a resident, resulting in the resident wetting through her brief and pants. Resident #4, who has a history of cerebral vascular accident, hypertension, diabetes mellitus type II, congestive heart failure, and muscle weakness, was observed on 05/31/24 at 11:17 AM being assisted to the bathroom by two nurse aides. The resident's brief was found to be saturated with urine and had stool smears, indicating a lack of timely care. The resident's care plan required peri-care every two hours and as needed to prevent skin breakdown and infection, but this was not adhered to. During an interview, NA #4, who was responsible for Resident #4's care during the 7:00 AM to 3:00 PM shift, admitted to not having rounded on the resident until 11:17 AM due to being busy. The Director of Nursing stated that it was expected for all residents to be checked every two hours and changed as needed, and if NA #4 was busy, she should have sought assistance from other staff members. The failure to provide timely incontinence care was attributed to NA #4's workload and the resident being left without care for an extended period.
Failure to Follow Enhanced Barrier Precautions During Wound Care
Penalty
Summary
The facility failed to adhere to its Infection Control Policy for Enhanced Barrier Precautions (EBP) during wound care for two residents. The Wound Nurse did not wear a gown while providing wound care to these residents, despite the policy requiring gown and glove use during high-contact activities such as wound care. The facility's policy, last updated in August 2022, mandates the use of EBPs to prevent the spread of multi-drug resistant organisms, especially for residents with wounds or indwelling medical devices. During observations, it was noted that personal protective equipment (PPE) was not available at the door or in a bin outside the room of one resident, and although PPE was available for the other resident, the Wound Nurse still failed to don a gown. Interviews with the Wound Nurse and the Assistant Director of Nursing/Infection Preventionist (ADON/IP) revealed that the Wound Nurse was aware of the requirement but forgot to wear a gown due to nervousness. The ADON/IP acknowledged the oversight and indicated that additional education would be provided to the Wound 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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