Highland House Rehabilitation And Healthcare
Inspection history, citations, penalties and survey trends for this long-term care facility in Fayetteville, North Carolina.
- Location
- 1700 Pamalee Drive, Fayetteville, North Carolina 28301
- CMS Provider Number
- 345353
- Inspections on file
- 30
- Latest survey
- March 13, 2026
- Citations (last 12 mo.)
- 6
Citation history
Health deficiencies cited at Highland House Rehabilitation And Healthcare during CMS and state inspections, most recent first.
The facility failed to protect residents from misappropriation of property when a nurse assumed control of a narcotic cart and, after a documented count of 103 Oxycodone tablets for a resident, the resident’s Oxycodone and associated narcotic sheets were later found missing, and when an Activities Assistant took and used the healthcare spending cards of two cognitively intact residents without their knowledge or consent. The Activities Assistant accessed cards that residents kept in their personal belongings, used them for in‑store purchases, and later claimed the residents had given permission and received cash back, which both residents denied. The Activities Director reported that the Activities Assistant had been facilitating online shopping with residents’ cards and that cards were supposed to be used only with the resident present, but the residents’ statements and transaction records showed unauthorized use of their benefits for the staff member’s personal purchases.
A resident with diabetes, glaucoma, and moderate cognitive impairment was referred to an outpatient ophthalmologist for bilateral eye burning and was ordered Refresh Tears QID and PRN Tylenol. A transport requisition was completed and a contracted Transportation Aide took the resident to the eye clinic, but clinic staff reported the resident could not be seen without someone accompanying him. After the facility informed the Transportation Aide that no one would accompany the resident, the appointment was not completed, and the resident experienced a medical emergency at the clinic and was sent to the ED. Facility records showed no evidence that the missed ophthalmology appointment was ever rescheduled, and the staff member responsible for tracking appointments had no record of any upcoming eye visit for this resident, despite leadership expectations that missed specialty appointments be rescheduled.
A resident with type 2 DM, severe cognitive impairment, and an unstageable sacral pressure ulcer was admitted with a documented sacral wound dressing in place, but no wound measurements were taken and no wound care orders or treatments were documented for the first four days after admission. Review of the TAR and medical record showed that wound care orders were not entered until several days later, at which point daily cleansing and topical treatments were initiated and then revised. Interviews with the former wound nurse, corporate nurse consultant, medical director, and wound PA confirmed there was no documentation that staff implemented wound care orders or contacted a provider or wound care company for orders during the initial gap, despite standing orders requiring MD or wound specialist direction for Stage 3 and 4 pressure injuries.
The facility failed to accurately code MDS assessments for three residents in the areas of falls and restraints. Two residents with neurological and mobility-related diagnoses had multiple documented falls without injury shortly after admission, yet their admission or discharge MDS assessments were coded as having no falls or inaccurately reflected the number and type of falls. A third cognitively impaired resident with no physician orders for restraints was incorrectly coded on a quarterly MDS as having a trunk restraint used less than daily, despite staff stating that no restraints were used. The MDS Coordinator acknowledged these errors as incorrect coding or oversight, while leadership stated they expected MDS assessments to be accurate and timely.
Surveyors found that two resident bathrooms on one hall were not maintained in a safe, clean, and homelike condition. In one shared bathroom, there was a strong urine odor, wet flooring near the toilet, visibly aged and discolored VCT tiles, and an uneven patch of cut tiles, while the door frame paint was peeling to bare metal. A resident reported disliking the persistent odor, and staff acknowledged noticing wet, foul-smelling floors but did not report the issue, despite awareness that a broken toilet flange caused water to back up and wet the floor. In another bathroom, the floor was extensively discolored, scuffed, and unwaxed, and door frames had peeling paint exposing metal; a resident stated the appearance made her feel bad and that she had previously raised the concern with the Administrator. Housekeeping and maintenance staff confirmed that discoloration could not be resolved by cleaning and that water sometimes seeped up through tiles when stepped on.
The facility failed to follow its smoking policy requiring all smoking materials to be secured in a lock box when not in use. A cognitively intact resident with a history of stroke, hemiplegia, vascular dementia, and anxiety, who required assistance with several ADLs and was coded for tobacco use, was observed in a day room with a lighter and cigarettes concealed in his clothing. One nurse reported not providing the materials and being unfamiliar with the smoking policy on that hall, while another nurse admitted knowing the resident did not turn in his lighter and that residents were allowed to smoke at any time, making supervision difficult. The Administrator stated that cigarettes were to be kept locked and lighters confiscated after smoking, but acknowledged that residents had been allowed to decide when to turn in their lighters, and some kept them due to frequent smoking.
A resident with a stroke diagnosis and moderately impaired cognition was not provided with showers as per her preference and care plan, receiving bed baths instead. Despite being able to communicate her desire for showers through head nods, staff documentation showed 'NO' or 'N/A' for scheduled shower days. Interviews revealed a lack of communication and coordination among staff, leading to the failure to honor the resident's preference.
A resident with chronic obstructive pulmonary disease reported an error on his facility trust fund account, where over $600 was taken without notification. Despite notifying the business office in April, no grievance was completed, and the issue remained unresolved. The Business Office Manager acknowledged the billing error but did not inform the Administrator or complete the necessary documentation. The Administrator only learned of the issue months later.
A resident with Parkinson's disease was incorrectly documented as having a feeding tube in the MDS assessment due to human error by the Assistant Dietary Manager. Interviews with staff confirmed the resident never had a feeding tube, highlighting a failure in accurate coding.
A facility failed to submit a PASRR application for a resident diagnosed with bipolar II disorder, despite a significant change in mental health status. The oversight was confirmed through record reviews and staff interviews, revealing that the Social Worker responsible for PASRR submissions did not submit a new application following the diagnosis.
A resident with a diagnosis of adult failure to thrive did not receive adequate nail care as per their care plan, resulting in long, uneven, and dirty nails. Despite being able to communicate her needs, the resident's request for nail care was not addressed by the facility staff, who were responsible for this task if not completed by hospice staff. The facility administrator was unaware of the resident's need for nail care, indicating a communication gap and failure to adhere to the care plan.
A resident was incorrectly charged for a full month's PML for skilled nursing care, despite only receiving care for two days. The error was identified in April, but the facility failed to correct it or reimburse the resident by December. The Business Office Manager and Administrator were unaware of the issue's extent until December, and DSS staff confirmed the billing should have been prorated.
Misappropriation of Narcotic Medication and Healthcare Spending Cards by Staff
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from misappropriation of their property, including a controlled substance and healthcare spending cards. For one resident receiving Oxycodone 10 mg every 4 hours as needed for pain, the contracted pharmacy documented delivery of 180 tablets, but the packing slip was not signed by a receiving nurse. A nurse working the day shift reported that at the end of her shift she counted 103 Oxycodone tablets for this resident on the narcotic cart with another nurse who presented herself as the oncoming agency nurse, took the keys, and assumed control of the cart. The following morning, another nurse reported that the resident had no Oxycodone available. Statements indicated that when the night nurse later counted narcotics with the next nurse, all narcotic counts and sheets matched what was called out, but there were no medications or narcotic sheets for this resident. The Quality Assurance nurse reported that the nurse who had taken over the cart was not actually scheduled to work that shift, had previously worked as an agency nurse, and left within about an hour of assuming the cart, after which the Oxycodone tablets and narcotic sheets for this resident were discovered missing. The deficiency also includes misappropriation of healthcare spending cards belonging to two cognitively intact residents by an Activities Assistant. One resident reported that her healthcare spending card, which she kept in a wallet in the bottom drawer of her nightstand, was missing and could not be located when staff searched her room. The resident’s insurance provider confirmed that the card had been used at a local retail store for a transaction of $95.00. The Activities Assistant stated that the resident had given her permission to take and use the card to purchase items for the resident and claimed she returned the card and cash, explaining that about $50.00 represented her portion of the items purchased. The resident denied giving permission for the Activities Assistant to take or use the card, denied knowing the Activities Assistant had possession of the card, and denied receiving any cash. The resident reported that the Activities Assistant later told her the purchases were made because the Activities Assistant’s children were hungry, and the resident expressed disappointment and concern that a similar incident could occur again. During the investigation of this first misappropriation, the facility identified a second cognitively intact resident whose healthcare spending card had also been used without permission. This resident had previously reported her card as misplaced to the Activities Assistant, who assisted her in canceling the card and ordering a replacement. Transaction records showed that the card had been used for multiple in-store purchases totaling $337.01, both before and after it was identified as missing. The resident stated she never made any in-store purchases with the card and that her last use of the card was for an online purchase with the help of the Activities Assistant. She reported being upset and believed the Activities Assistant should be held accountable for using her card without permission. The Activities Director confirmed that the Activities Assistant facilitated online shopping for residents using a tablet and that healthcare spending cards were supposed to be used only when the resident was present during the transaction. The Activities Director also reported that the Activities Assistant later claimed to have gone to a store after hours for one resident with alleged permission to use the card, while the resident denied granting such permission. The Administrator stated that her expectation was that all staff follow the facility’s policy related to misappropriation of resident property. The facility’s abuse policy defined misappropriation as the deliberate misplacement, exploitation, or wrongful use of a resident’s money or belongings and affirmed residents’ right to be free from misappropriation of their property. Despite this policy, the events described show that a resident’s narcotic pain medication and two residents’ healthcare spending cards were wrongfully taken or used without their knowledge or consent, constituting misappropriation of resident property.
Failure to Reschedule Missed Ophthalmology Appointment After Unaccompanied Visit
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident obtained ordered ophthalmology services after a missed appointment. The resident had diagnoses including type 2 diabetes, glaucoma, and coronary artery disease, and a physician progress note documented bilateral eye burning. On the following day, the physician ordered a referral to an outpatient ophthalmologist, along with Refresh Tears ophthalmic solution four times daily for dry eyes and PRN Tylenol for pain. A quarterly MDS showed the resident had moderate cognitive impairment, was coded as having adequate vision without corrective lenses, and was coded as not having pain or receiving pain interventions. A transport requisition was completed for an eye appointment at an outpatient office, and the contracted Transportation Aide reported picking up the resident and signing him in for the appointment. Shortly after leaving, the outpatient office called the Transportation Aide to report that the resident could not be seen without someone accompanying him. The Transportation Aide called the facility and was told there was no one available to accompany the resident. When the Transportation Aide returned to the outpatient office, she learned the resident was having a medical emergency and had been transported by ambulance to the ED. Later that day, she picked the resident up from the ED and returned him to the facility. Record review showed no evidence that the missed ophthalmology appointment was ever rescheduled. The Medical Supplies Personnel, who maintained a calendar and transportation requisition forms, had no record of any upcoming eye appointment for the resident. The MARs indicated the ordered eye drops were administered four times daily and PRN Tylenol was given once for a reported pain level of 4/10, with all other documented pain assessments at 0. Attempts to interview the resident about his vision and eye appointments were unsuccessful. The Unit Manager confirmed the resident did not receive ophthalmology services on the day of the missed appointment and stated she had called the eye clinic and was waiting for a call back to reschedule, but there was no documentation of a new appointment. The Medical Director and Administrator both stated their expectations that specialty referrals and any missed appointments be scheduled or rescheduled so residents receive needed medical services, which did not occur in this case.
Failure to Initiate Timely Wound Care for Admitted Resident With Sacral Pressure Ulcer
Penalty
Summary
Facility staff failed to initiate and document pressure ulcer treatment for a newly admitted resident with a known sacral pressure injury for four days following admission. The resident was admitted with type 2 diabetes, severe cognitive impairment, dependence on staff for hygiene, mobility, and transfers, and an unstageable sacral pressure ulcer documented as present on admission. The admission MDS and skin assessment identified the sacral pressure ulcer and noted a clean, dry dressing, but the skin assessment did not include wound measurements. Review of the medical record and Treatment Administration Record (TAR) showed no wound care orders or documented sacral wound treatment on the four days immediately following admission. On a later date, a wound care order was entered on the TAR for daily cleansing of the sacrum and application of medical grade honey for a Stage 3 pressure injury, and this order was then discontinued and replaced the same day with a new order for cleansing, Santyl, and quarter-strength antimicrobial-moistened gauze for an unstageable pressure injury. Interviews with the former Wound Treatment Nurse, Corporate Nurse Consultant, Medical Director, and Wound PA confirmed there was no evidence that wound care orders had been implemented or that staff had contacted a provider or the wound care company for wound treatment orders during the four-day gap after admission, despite standing orders that required MD or wound specialist orders for Stage 3 and 4 wounds. The Wound PA noted that weekly wound evaluations began only after the initial wound consult, and there was no documentation that facility staff had reached out to the consulting company prior to that evaluation.
Inaccurate MDS Coding for Falls and Restraints
Penalty
Summary
The facility failed to ensure accurate coding of the Minimum Data Set (MDS) for falls and restraints for three residents. One resident with epilepsy experienced multiple documented falls over several days, including being found on the floor on his buttocks, lying on his side on a fall mat, sliding from a wheelchair to the ground, and being observed on the floor beside his wheelchair, all with no injury noted. Despite these documented events, his discharge MDS indicated no falls with no injury, one fall with injury, and no falls with major injury. The MDS Coordinator, who completed this assessment, acknowledged awareness of the resident’s multiple falls and confirmed that the discharge MDS was incorrectly coded for falls, though she was unsure how the error occurred. The Administrator stated she expected all MDS assessments to be accurate and timely. Another resident admitted with cerebrovascular accident and muscle weakness had two documented falls on the same day, both witnessed and without injury, one from attempting to get out of bed and another from trying to get out of a chair. However, the admission MDS for this resident indicated there had been no falls since admission. The MDS Coordinator, who completed this assessment, confirmed the MDS was incorrectly coded for falls and could not explain how the error occurred. A third resident, admitted with cerebral infarction and vascular dementia and with no physician orders for physical restraints, was coded on a quarterly MDS as having a trunk restraint used less than daily. The MDS Coordinator stated that this resident did not have a restraint and that there were no restraints used in the facility, characterizing the restraint coding as an oversight. The Regional Nurse Consultant and the Administrator both stated their expectation that MDS assessments be coded correctly.
Failure to Maintain Clean, Odor-Free, and Well-Maintained Resident Bathrooms
Penalty
Summary
The deficiency involves the facility’s failure to maintain two resident bathrooms and associated door frames in good repair and to ensure one bathroom was free of urine odor on one hall, affecting three cognitively intact residents. Surveyors observed that the shared bathroom for two residents had a very strong urine odor detectable upon entering the room, with cream VCT flooring that was grayish, aged, scuffed, scratched, and lacking finish or wax. The floor near the toilet base was wet, and a corner of the bathroom floor had three cut tile pieces placed on top of the original floor, creating an uneven, non‑smooth surface that was not easily cleanable. One resident in this room, who was incontinent and did not use the bathroom, reported that he could smell the odor from his bed and did not like it, and he had not reported it because he believed anyone entering the room could smell it. The other resident using the toilet independently did not provide details about the duration or his feelings about the bathroom condition. Staff interviews confirmed awareness of the bathroom’s condition and odor. A nursing assistant stated that the resident who used the toilet did so all the time and that she had noticed the floor to be wet at times with a bad smell, but she did not report it because she believed anyone entering the room could see and smell the problem. The housekeeper assigned to the hall reported finding water on the floor and an odor in the shared bathroom and stated that the Housekeeping Supervisor was aware. The Housekeeping Supervisor later reported that water would sometimes seep up through the bathroom floor tiles in this bathroom when someone stepped on the floor. The Regional Maintenance Manager stated that the toilet flange in this bathroom was broken, causing water to back up and wet the floor when the toilet was flushed, and acknowledged that it should have been fixed. A separate bathroom used by another cognitively intact resident on the same hall was also found to be in poor condition. Surveyors observed that this bathroom’s cream VCT floor had black and gray discoloration over most of the surface, appeared aged, scuffed, scratched, and lacked finish or wax, and that the lower portions of the bathroom door frames on both sides had peeling paint exposing brown metal. The resident reported using the bathroom but stated she did not like how it looked, that it made her feel bad, and that she sometimes tried to clean it herself to improve its appearance. She also reported having discussed the bathroom condition with the Administrator months earlier and was told the facility would try to wax and buff the floor to improve it. The Housekeeping Supervisor stated that attempts to clean and treat the floors in both this bathroom and the shared bathroom had not resolved the discoloration and that the floors required replacement, and he indicated the door frames would be repainted when the bathroom floors were fixed. The Administrator acknowledged being aware of the bathroom floor discoloration and environmental issues on the hall since several months prior, based on her rounds.
Failure to Secure Resident Smoking Materials per Facility Policy
Penalty
Summary
The facility failed to secure smoking materials in accordance with its smoking policy, which required all resident smoking materials to be maintained in a secure lock box at the nurses' station when not in use. A cognitively intact resident with a history of cerebral infarction with resulting hemiplegia, hemiparesis, aphasia, dysphagia, vascular dementia with mood disturbance, and anxiety was observed sitting in a day room with a lighter and two cigarettes concealed in the bottom of his shirt. His MDS indicated he required assistance with several ADLs and was coded for tobacco use. A smoking evaluation documented that he was considered an independent, safe smoker whose preference to smoke independently at times of his choice was honored. During interviews, one nurse stated she had not provided the resident with smoking materials and did not know where the cigarettes or lighter came from, and also reported she was unfamiliar with the smoking policy because it was her first time working on that hall. Another nurse, who regularly worked with the resident, acknowledged she was aware that he did not turn in his lighter after smoking and that residents were allowed to smoke whenever they wished, making it difficult for staff to track smoking times. She stated that residents were supposed to give their lighters and cigarettes to the nurse upon returning from smoking, but this was not occurring with this resident, who liked to keep his lighter due to frequent smoking. The Administrator confirmed that cigarettes were to be kept in a locked box at the nurses' station and that nurses were supposed to confiscate lighters after each smoking session, but also stated that residents had effectively been allowed to decide whether to turn in lighters at the end of each session or at the end of the day, with some residents keeping lighters because they smoked frequently.
Failure to Honor Resident's Shower Preference
Penalty
Summary
The facility failed to honor a resident's preference for showers, instead providing bed baths, which constitutes a deficiency in respecting resident self-determination and choice. The resident, who was admitted with a diagnosis of stroke and had moderately impaired cognition, was able to communicate her needs through head nods. Her care plan specified assistance with activities of daily living, including scheduled showers twice a week. However, documentation and interviews revealed that the resident consistently received bed baths instead of showers, with staff marking 'NO' or 'N/A' on the Kardex for scheduled shower days. Interviews with staff and the resident's family member confirmed the resident's desire for showers, which were not provided as scheduled. Nursing assistants reported various reasons for not providing showers, including shifts not completing the task and the resident's occasional refusal due to pain. Despite these refusals, the resident's family and the resident herself indicated a preference for showers, which were not consistently offered or provided. The lack of communication and coordination among staff contributed to the failure to meet the resident's preferences, as some staff were unaware of the resident's desire for showers or the need to offer them even after a bed bath.
Failure to Address Resident Grievance Regarding Trust Fund Error
Penalty
Summary
The facility failed to honor a resident's right to voice grievances without discrimination or reprisal, as required by regulations. A resident, diagnosed with chronic obstructive pulmonary disease, reported an error on his facility trust fund account statement, where over $600 was taken without notification. The resident noticed this discrepancy in April 2024 and reported it to the business office. However, the business office did not complete a written grievance, and the issue remained unresolved for several months. The Business Office Manager acknowledged the error in billing for a second patient monthly liability for February 2024 but did not notify the Administrator or complete the necessary grievance documentation. The Administrator only became aware of the issue in December 2024, after speaking with the resident and the Business Office Manager.
MDS Coding Error for Feeding Tube
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) Assessment for a resident in the area of feeding tubes. The resident, who was admitted with a diagnosis of Parkinson's disease, was documented as having a feeding tube in the quarterly MDS assessment, despite being moderately cognitively impaired and never having had a feeding tube while at the facility. This error was identified through interviews with staff, including a nurse, the MDS Coordinator, and the Assistant Dietary Manager. The Assistant Dietary Manager admitted to mistakenly marking the resident as having a feeding tube due to human error. The Director of Nursing expressed that it was expected for the MDS assessment to be coded accurately.
Failure to Submit PASRR Application for New Mental Health Diagnosis
Penalty
Summary
The facility failed to complete a Preadmission Screening and Resident Review (PASRR) application for a resident who developed a new mental health diagnosis. The resident, who was readmitted to the facility with vascular dementia and psychotic disturbance, was later diagnosed with bipolar II disorder. Despite this significant change in mental health status, a new PASRR application for a level II screen was not submitted as required. The oversight was identified during a review of the resident's records and confirmed through staff interviews. The Social Worker, responsible for submitting PASRR determinations, acknowledged that a new application should have been submitted following the resident's diagnosis of bipolar II disorder. The Administrator also confirmed that the PASRR level I was negative and recognized the failure to submit a new application after the new diagnosis was made.
Failure to Provide Adequate Nail Care for a Resident
Penalty
Summary
The facility failed to provide adequate nail care for a dependent resident, identified as Resident #23, who was admitted with a diagnosis of adult failure to thrive. The resident's care plan indicated a need for assistance with activities of daily living, including personal care such as bathing and dressing. Despite this, observations and interviews revealed that the resident's nails were long, uneven, jagged, and had black soil underneath, indicating a lack of proper nail care. The resident, who was cognitively impaired but able to communicate her needs, expressed a desire for her nails to be cleaned and trimmed, which she could not do herself. Interviews with nursing assistants and a nurse confirmed that the facility staff were responsible for providing nail care if it was not completed by hospice staff during bathing. However, the assigned nursing assistant had not offered nail care and was unaware of the reason for this oversight. The facility administrator was also unaware of the resident's need for nail care, highlighting a communication gap and a failure to adhere to the resident's care plan. This deficiency affected one of the three sampled residents, demonstrating a lapse in the facility's duty to provide necessary personal care to its residents.
Failure to Correct Billing Discrepancy in Resident's Trust Fund
Penalty
Summary
The facility failed to manage a resident's financial affairs properly, specifically regarding a billing discrepancy in the resident's facility trust fund account. Resident #24 was charged for a full month's patient monthly liability (PML) for skilled nursing care in February 2024, despite only receiving care for two days starting on February 27, 2024. This error was identified in April 2024 by the Business Office Manager, who had just started the position. Despite the resident's repeated complaints and the Business Office Manager's communication with the corporate billing office and the Department of Social Services (DSS), the error was not corrected, and the resident was not reimbursed by December 2024. The Business Office Manager and the Administrator were not aware of the full extent of the issue until December 2024, when the resident reiterated his complaint. The DSS staff and supervisor were also unaware of the discrepancy until December 2024, despite previous communications from the facility. The DSS staff confirmed that the PML should have been prorated for the two days of care, but the system had billed for the entire month. The DSS supervisor initiated the process to correct the billing error and reimburse the resident, but this action was not completed at the time of the report.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
