Huntersville Health & Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Huntersville, North Carolina.
- Location
- 13835 Boren Street, Huntersville, North Carolina 28078
- CMS Provider Number
- 345570
- Inspections on file
- 25
- Latest survey
- April 23, 2026
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Huntersville Health & Rehabilitation Center during CMS and state inspections, most recent first.
A severely cognitively impaired resident with Alzheimer’s disease, who required assistance with ADLs and had known combative behaviors during care, became agitated and resistive while two NAs were providing incontinence care and dressing. One NA reported that the other NA responded to the resident’s attempts to bite and swing by striking the resident three times with an open hand—once on the lips, once on the cheek, and once on the back of the head—while telling the resident she would not be allowed to hit or bite staff. The reporting NA continued care after the first strike, did not immediately remove the other NA from the room, and only reported the incident after completing the transfer, resulting in a failure to protect the resident from staff-to-resident physical abuse.
A resident with Alzheimer’s disease and severe cognitive impairment, care planned for combative behaviors, became agitated and resistive during incontinence care. One NA removed the resident’s hands from the bed rail, placed them on the resident’s chest, and held them there to stop her from swinging her arms while another NA completed care. While the resident’s hands were being held down, she attempted to bite the NA, who then struck her on the lips with an open hand and told her she would not be allowed to fight or bite, continuing to restrain her. The resident became more agitated and began kicking. Staff later acknowledged they had been trained on abuse and restraints but did not recognize at the time that holding the resident’s hands down constituted a physical restraint and that care should have been stopped and attempted later.
A cognitively impaired resident with Alzheimer’s disease, known to be resistive to care, was being assisted with incontinence and dressing care by two NAs when the resident became agitated, grabbed the bed rail, and attempted to bite. One NA responded by striking the resident on the lips with an open hand and stating the resident would not fight or bite them, while the assisting NA, though shocked, continued providing care instead of stopping and intervening. As care and a subsequent transfer to a wheelchair continued, the resident swung at staff, and the same NA struck the resident two additional times—once on the face and once on the back of the head—while repeating similar statements. The assisting NA only removed the resident from the room and reported the incident after completing the transfer, later acknowledging she should have stopped care and removed the other NA after the first strike, demonstrating a failure to follow the facility’s abuse prevention and immediate reporting policy.
A resident with moderate cognitive impairment was discharged home with a midline IV catheter still in place, despite no ongoing need for IV access. The discharge summary did not indicate any devices, and staff interviews revealed the discharge was rushed and lacked proper education for the resident and responsible party. The oversight was acknowledged by nursing leadership and the medical director.
A resident with bipolar disorder was admitted with an expired PASRR level II, and facility staff failed to obtain a new level II assessment as required. Both the Assistant Discharge Planner and Discharge Planner were responsible for monitoring PASRRs but did not recognize the need for a new assessment, resulting in the deficiency.
A resident undergoing outpatient dialysis for stage 5 CKD was not provided with a bagged lunch on two treatment days, despite the facility's process for preparing such meals. The assigned nurse aide forgot to retrieve the prepared lunches, resulting in the resident returning hungry after dialysis. Both dietary and administrative staff confirmed that the lunches were available but not delivered as required.
A Treatment Nurse did not perform hand hygiene between glove changes while providing wound care to a resident, contrary to facility policy. The nurse was observed removing and donning gloves multiple times without sanitizing hands in between, even after handling soiled dressings and before touching clean supplies and wounds. The nurse later stated she was aware of the requirement but forgot due to nervousness. Both the IP and DON confirmed that hand hygiene is expected after each glove removal and before new gloves are put on during wound care.
A Wound Nurse failed to follow the facility's Enhanced Barrier Precautions (EBP) policy by not wearing a gown while providing care to a resident under transmission-based precautions. Despite signage instructing the use of gowns and gloves, the nurse only wore gloves during incontinence and wound care. The nurse admitted to forgetting the gown, and the DON confirmed staff were expected to adhere to posted precautions.
Failure to Protect Cognitively Impaired Resident From Staff Physical Abuse During Care
Penalty
Summary
The deficiency involves the facility’s failure to protect a severely cognitively impaired resident from staff-to-resident physical abuse during the provision of care. The resident had Alzheimer’s disease, was coded on the MDS with severe cognitive impairment, required moderate assistance with personal hygiene, toileting, dressing, and transfers, and was always incontinent of bowel and bladder. The resident had been care planned for combative behaviors with care, with interventions to assure safety, listen to the resident, and try to calm her. During an episode of incontinence care and dressing, the resident became agitated, was swinging her arms, and attempted to bite staff. According to the eyewitness account from NA #1, NA #2 responded to the resident’s resistive and combative behavior by striking the resident multiple times with an open hand. NA #1 reported that when the resident tried to bite NA #2 while holding onto the bed rail, NA #2 removed the resident’s hands from the rail and then “popped” the resident on the lips with an open hand, stating, “you’re not going to fight us or bite us,” with an audible popping sound. NA #1 continued providing incontinence care and did not immediately stop the interaction or remove NA #2 from the room. As care progressed, while the resident was seated at the edge of the bed and attempting to swing at NA #1, NA #2 again struck the resident on the left side of the face/cheek with an open hand, with a similar audible pop, and repeated the same statement. NA #1 further reported that during the transfer from bed to wheelchair, while the resident was mid-transfer and swinging her arms, NA #2 struck the resident a third time on the back of the head with an open hand, again telling the resident she was not going to hit staff. After each strike, the resident did not vocalize but appeared more agitated in facial expression. NA #1 acknowledged that she was in shock, continued care after the first strike, and did not immediately remove NA #2 from the room or stop the care. The DON later stated that both NAs should have stopped providing care when the resident became agitated and that NA #1 should have asked NA #2 to leave the room and reported the incident after the first strike. The Administrator’s account of NA #1’s report was consistent with NA #1’s description that NA #2 made open-hand contact with the resident’s mouth, face, and the back of the head during care.
Improper Use of Physical Restraint During Care of Combative Resident
Penalty
Summary
The deficiency involves the failure to protect a resident’s right to be free from physical restraints when a nurse aide held the resident’s hands down against her chest during care. The resident had Alzheimer’s disease, was assessed with severe cognitive impairment on the admission MDS, and had been care planned for combative behaviors with interventions such as assuring safety, listening, and attempting to calm her. During an episode of care, the resident became agitated, was swinging her arms, and grabbed the bed rail, making it difficult for staff to move her. Nurse Aide #2 removed the resident’s hands from the bed rail, placed them on the resident’s upper chest, and held them there to prevent her from swinging her arms while Nurse Aide #1 completed incontinence care. Nurse Aide #1 reported that while Nurse Aide #2 was holding the resident’s hands down, the resident attempted to bite Nurse Aide #2, who then struck the resident on the lips with an open hand and told her she was not going to fight or bite them, continuing to restrain the resident’s hands. The resident became more agitated and began kicking her legs, making it more difficult to finish care. Nurse Aide #1 later stated she had received training on dealing with resident behaviors and abuse but did not realize at the time that holding the resident’s hands down on her chest constituted a restraint, and acknowledged that care should have been stopped and attempted later. The DON and Administrator confirmed that Nurse Aide #2 had held the resident’s hands against her chest to prevent injury and acknowledged that the resident’s hands were restrained when she was struck, and that staff had previously received training on all types of abuse, including physical restraints.
Failure to Protect Resident From Physical Abuse and Immediate Reporting of Incident
Penalty
Summary
The deficiency involves the facility’s failure to implement its abuse policy requiring all employees to immediately report any suspected or witnessed abuse to the Administrator, DON, or immediate supervisor, and to protect residents from abuse. The policy, dated 10/17/23, states that all employees are responsible for immediate reporting and for prevention of abuse and neglect by advocating and enforcing resident rights. Resident #1, who had Alzheimer’s disease and a history of being resistive to care, was the subject of the incident. On the date of the event, NA #2 requested assistance from NA #1 to provide care to Resident #1, who was agitated and partially out of bed when NA #1 entered the room. During incontinence and dressing care, Resident #1 grabbed the bed rail and became difficult to move. NA #2 removed the resident’s hands from the rail, held them on the resident’s upper chest to prevent swinging, and when the resident attempted to bite, NA #2 struck the resident on the lips with an open hand and stated that the resident was not going to fight or bite them. NA #1 reported being shocked but continued providing incontinence care instead of stopping the interaction. As care continued, Resident #1 became more agitated and began kicking, and NA #1’s focus remained on quickly finishing care and getting the resident away from NA #2, rather than immediately stopping care and intervening after the first strike. After incontinence care, NA #1 sat Resident #1 on the edge of the bed to change her shirt while NA #2 stood near the end of the bed behind the resident. When the resident’s arm became stuck in the shirt and the resident swung at NA #1, NA #2 struck the resident a second time on the left side of the face with an open hand, again stating the resident was not going to fight or bite them. NA #1 told NA #2 to stop and indicated she could manage the care, but continued the transfer. During the transfer from bed to wheelchair, when the resident swung her arms again, NA #2 struck the resident a third time on the back of the head with an open hand, repeating that the resident was not going to hit them. NA #1 then completed the transfer, removed the resident from the room, and reported the incident to the Unit Manager. NA #1 later acknowledged that, in retrospect, she should have stopped care after the first strike, removed NA #2 from the room, and reported the incident immediately, indicating a failure to follow the facility’s abuse prevention and reporting policy in real time during the incident.
Resident Discharged Home with Midline Catheter Left In Place
Penalty
Summary
A deficiency occurred when the facility failed to ensure the safe and orderly discharge of a resident who was sent home with a midline intravenous (IV) catheter still in place, despite no ongoing medical need for the device. The resident, who had moderate cognitive impairment and was admitted with diagnoses including dysphagia and hyponatremia, had previously received IV fluids via the midline catheter for hyponatremia. The discharge summary did not indicate any devices or orders requiring IV access upon discharge. However, the resident was discharged with the midline catheter still inserted in her arm. The responsible party discovered the catheter upon arrival home and contacted the facility. Interviews with staff revealed that the discharge was rushed, and there was a lack of recall regarding the education provided to the resident and her responsible party about the catheter. The unit manager and DON confirmed that the midline catheter should have been removed prior to discharge, and the medical director acknowledged this was an oversight by nursing staff. The interdisciplinary team had discussed discharge needs, but the removal of the midline catheter was not completed as required.
Failure to Complete Required PASRR Level II Assessment for Resident with Expired Authorization
Penalty
Summary
The facility failed to complete a required Preadmission Screening and Resident Review (PASRR) level II for a resident who had a history of bipolar disorder. The resident was admitted with a PASRR level II that had expired prior to admission, and no new level II PASRR was obtained after admission. Record review confirmed that the expired PASRR was not updated, and the necessary assessment was not completed as required. Interviews with facility staff revealed that both the Assistant Discharge Planner and the Discharge Planner were responsible for monitoring and completing level II PASRRs. The Assistant Discharge Planner was unaware that the resident's PASRR was a level II that had expired, mistakenly believing it was a level I, and therefore did not obtain a new assessment. The Discharge Planner acknowledged that a new level II PASRR should have been obtained but was overlooked. The Administrator confirmed that the responsibility for ensuring current level II PASRRs rested with the Discharge Planner and Assistant Discharge Planner.
Failure to Provide Bagged Lunch for Dialysis Resident
Penalty
Summary
A deficiency occurred when a resident with stage 5 chronic kidney disease, who was admitted for short-term rehabilitation and required outpatient dialysis three times a week, was not provided with a bagged lunch on the days of her dialysis treatments. The resident reported that she left the facility for dialysis after having breakfast in the morning and returned in the late afternoon, expressing that she was very hungry upon return as no lunch was provided. The facility had a process in place where the dietary department prepared bagged lunches for dialysis days, and nursing staff were responsible for retrieving and sending the lunch with the resident. Despite this process, the assigned nurse aide admitted to forgetting to collect and send the bagged lunch with the resident on two separate occasions. The dietary manager confirmed that the lunches were prepared and available in the kitchen on those days, but was unaware that they were not delivered to the resident. The medical director and administrator both acknowledged that a bagged lunch should have been provided to the resident on dialysis days.
Failure to Follow Hand Hygiene Protocol During Wound Care
Penalty
Summary
A deficiency was identified when a Treatment Nurse failed to follow the facility's Hand Hygiene policy during wound care for a resident. The nurse was observed performing wound care procedures, including cleaning and dressing two wounds, but did not sanitize her hands each time after removing gloves and before donning new gloves, as required by policy. The nurse washed her hands at the start and end of the procedure but neglected to perform hand hygiene between glove changes, even after handling soiled dressings and before touching clean supplies and the resident's wounds. The nurse acknowledged during an interview that she was aware of the hand hygiene requirements but attributed her lapses to nervousness during the observation. The Infection Preventionist and Director of Nursing both confirmed that the expectation is for staff to sanitize hands after each glove removal and before putting on new gloves during wound care. The incident was observed during a wound care session for a resident with wounds on the left thigh, and the nurse's failure to perform proper hand hygiene was directly witnessed by surveyors.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement its policy for Enhanced Barrier Precautions (EBP) when a Wound Nurse did not don a gown before entering a resident's room to provide care. The resident was under transmission-based precautions due to a wound located on the sacrum. The facility's policy, dated March 26, 2024, required the use of gowns and gloves during high-contact resident care activities, including wound care. Despite the EBP signage on the resident's door instructing staff to wear a gown and gloves, the Wound Nurse entered the room, performed hand hygiene, applied gloves, and provided incontinence and wound care without wearing a gown. During an interview, the Wound Nurse acknowledged that the resident was under Enhanced Barrier Precautions and admitted to forgetting to put on a gown, although she typically wore one while providing wound care. The Director of Nursing confirmed that all staff were expected to follow the precautions posted on residents' doors and use the assigned personal protective equipment (PPE). The observation and interviews revealed that the Wound Nurse should have worn a gown while providing care to the resident, as per the facility's infection control policy.
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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