Margate Health And Rehabilitation, Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Jefferson, North Carolina.
- Location
- 540 Waugh Street, Jefferson, North Carolina 28640
- CMS Provider Number
- 345296
- Inspections on file
- 21
- Latest survey
- February 13, 2026
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Margate Health And Rehabilitation, Llc during CMS and state inspections, most recent first.
A resident with Type 2 DM, cognitively intact and receiving weekly tirzepatide (Mounjaro) injections, had four pens delivered and stored in a locked refrigerator, treated like narcotics. When an RN attempted to administer the scheduled weekly dose, the first pen retrieved was already unlocked with the cap depressed and no medication available, and a second pen for the same resident was found in the same empty, used state. The resident reported that two pens were empty when the nurse tried to give the injection and that the dose was given several days late after new medication was obtained. The UM, Wound Nurse, and other staff confirmed both pens appeared used when compared to another resident’s unused pen, while pharmacy and manufacturer representatives indicated such defects would typically be detected before shipment. Multiple nurses and leadership could not explain why the pens were empty, and leadership acknowledged they did not initially consider or report potential misappropriation of the resident’s medication.
A cognitively intact resident with Type 2 DM had two tirzepatide (Mounjaro) pens found empty when a nurse attempted to administer the scheduled weekly injection, requiring replacement medication from the pharmacy and resulting in a delayed dose. The nurse and UM confirmed both remaining pens for this resident were already activated and empty, based on comparison with another resident’s unused pen. Although facility policy required immediate investigation and reporting of suspected abuse, neglect, exploitation, or misappropriation to the Administrator, State Agency, APS, and other agencies, no formal investigation into the empty pens was conducted and no report of potential misappropriation was made to the State Agency or other required entities.
A wound nurse failed to consistently follow the facility’s hand hygiene policies while performing multiple pressure ulcer treatments on a resident. Although the nurse initially washed her hands and donned appropriate PPE, she repeatedly removed soiled gloves and applied clean gloves without performing required hand hygiene between several steps of the wound care on the hip and sacral areas. In interviews, the nurse acknowledged she knew hand hygiene was required between glove changes but stated she lost track due to multiple glove changes and nervousness while being observed, while the IP and Administrator confirmed that policy requires hand hygiene every time gloves are removed.
A resident admitted with multiple cardiac and respiratory diagnoses received continuous oxygen therapy as ordered and documented in the care plan and MAR, but the admission MDS assessment failed to reflect this therapy. The MDS Nurse acknowledged the omission was an oversight during a transition to a new electronic health record system.
A resident with a physician's order for continuous oxygen was transported to the ER without receiving oxygen during the transfer. Upon arrival, the resident was found to be unresponsive and hypoxic, with an oxygen saturation of 81% on room air. Facility staff and the transportation aide could not confirm if oxygen was provided during transport, and ER staff documented that the resident arrived without oxygen despite the standing order. This resulted in a deficiency related to the failure to implement safe and appropriate respiratory care.
A resident suffered multiple fractures and later died after a Nurse Aide, whose competencies were not verified, improperly performed care. The NA rolled the resident onto her side on an air mattress, which decompressed, causing the resident to fall. The facility failed to ensure the NA's competencies were verified before taking assignments independently, leading to immediate jeopardy.
A resident with severe cognitive impairment and mobility issues fell from bed due to inadequate assistance during incontinence care. The NA attempted the care alone, despite the resident's need for two-person assistance, resulting in the resident sustaining multiple fractures. The resident was transferred to the hospital and later died, with respiratory failure noted as the cause of death.
A resident's preference for communal dining was not honored due to a COVID-19 outbreak and a subsequent hurricane, which delayed the resumption of group dining. Despite the resident's cognitive impairment and need for supervision, the facility had not offered communal dining for several months, affecting meal intake and resident satisfaction.
The facility failed to communicate its efforts to address recurring concerns raised by residents during Resident Council meetings, particularly regarding meal choices and dietary issues. Despite these concerns being documented and presumably addressed internally, residents did not receive feedback, leading to feelings of being unheard and undervalued. Interviews with staff and the Administrator confirmed a lack of communication back to the residents, resulting in repeated grievances and dissatisfaction.
The facility failed to follow its Enhanced Barrier Precautions (EBP) policy for residents with indwelling medical devices and wounds. A resident with a feeding tube did not have proper EBP signage, and staff did not wear the required PPE during care. Another resident with a pressure ulcer was not placed on EBP, and staff did not use the necessary PPE. Additionally, staff failed to don gowns during wound care for a resident with a stage 3 pressure ulcer, despite EBP signage. Miscommunication and misunderstanding of EBP criteria contributed to these deficiencies.
The facility failed to ensure staff received training on Enhanced Barrier Precautions (EBP) and did not effectively communicate which residents required EBP. Four nursing staff members were not familiar with EBP, and there was no consistent method to inform staff about residents needing EBP, particularly those with indwelling medical devices. The Infection Preventionist and Administrator acknowledged the confusion among staff regarding EBP implementation.
The facility failed to provide required dementia and abuse training for six nurse aides, as revealed through record reviews and staff interviews. The nurse aides, hired between 1992 and 2024, lacked documented training in abuse prevention or dementia care for the period from November 2023 to November 2024. Interviews with the SDC and DON highlighted a lack of clarity and communication regarding training responsibilities, with the SDC unaware of the missing records and the DON acknowledging turnover in the SDC position.
A resident with Type 2 diabetes did not receive their scheduled semaglutide dose due to medication unavailability. The nurse documented administration but found insufficient medication in the pen. The pharmacy indicated it was too early for a refill, and the nurse failed to promptly inform the Nurse Supervisor or seek provider instructions. The issue was only addressed two days later, highlighting a lapse in protocol adherence.
Two residents in an LTC facility had air mattresses set incorrectly for their weights, impacting pressure ulcer care. One resident, weighing 123.8 pounds, had a mattress set to 240 pounds, while another, weighing 90 pounds, had settings fluctuating between 160 and 240 pounds. Staff interviews revealed a lack of process for monitoring and adjusting mattress settings, with initial setup done by the Maintenance Director based on nurse input.
A resident with COPD was found to have an oxygen concentrator with a filter caked in dust, indicating a failure in maintenance. Staff interviews revealed confusion over cleaning responsibilities, with nurse aides, nurses, and central supply unsure of their roles. The environmental services director acknowledged the oversight, and both the DON and administrator expected housekeeping to ensure cleanliness, which was not done.
A resident with diabetes did not receive their prescribed semaglutide dose due to an inadequate amount in the medication pen. Despite this, a nurse documented the medication as administered. The error was discovered when the resident reported the missed dose to the Nurse Supervisor, who confirmed the discrepancy with the nurse involved.
Failure to Safeguard Resident’s Tirzepatide Pens From Misappropriation
Penalty
Summary
The deficiency involves the facility’s failure to protect a cognitively intact resident’s right to be free from misappropriation of medication, specifically tirzepatide (Mounjaro) prescribed for Type 2 diabetes mellitus. The resident had a physician’s order for a weekly subcutaneous injection of tirzepatide 5 mg/0.5 ml on Fridays. Pharmacy records showed that four tirzepatide injections (2 ml total) were delivered and charged to the resident’s insurance. The pens were stored in a locked box in the medication room refrigerator and treated like narcotics. Multiple nurses confirmed that the pens were received and placed in the refrigerator, with at least one nurse stating she visually confirmed that the pens contained medication at the time of delivery. On the scheduled administration date, the assigned nurse retrieved a tirzepatide pen from the refrigerator to give the resident her weekly injection and found the pen already unlocked with the purple cap depressed and no medication available to inject. After involving the Wound Nurse and the Unit Manager, they inspected the remaining tirzepatide pen for the resident and discovered that it was also empty, with the purple cap depressed and the plunger visible, indicating the medication had already been expressed. The resident reported that the nurse attempted to give the weekly tirzepatide injection but found the syringe empty, then obtained another syringe that was also empty. The resident stated she ultimately received the injection two or three days later after additional medication was obtained, and that while she had previously experienced delays waiting for pharmacy delivery, she had never before encountered empty pens when nurses attempted to administer the medication. The Unit Manager, acting as DON at the time, compared the two empty pens to another resident’s tirzepatide pen and confirmed that the empty pens appeared used, with the purple caps depressed, unlike the unused pen. The Unit Manager notified the Administrator, Regional Clinical Manager, and NP that the pens were empty and contacted the pharmacy to request replacement medication. The pharmacy manager stated that the resident’s insurance was billed for the pens, that the pens are individually labeled and repackaged by the pharmacy, and that any damaged or empty pens would typically be identified before shipment. A manufacturer representative also stated that while pens could potentially leak, such issues would likely be noticed by the pharmacy during repacking. Multiple nurses, including those who had administered prior and subsequent tirzepatide doses, reported no prior issues with empty pens and could not explain why the two pens for this resident were empty. The Unit Manager and Administrator both acknowledged they did not initially consider misappropriation of medication when the empty pens were discovered, despite the medication being described as expensive and highly sought after.
Failure to Report and Investigate Possible Misappropriation of Tirzepatide
Penalty
Summary
The deficiency involves the facility’s failure to implement its abuse, neglect, and exploitation policy regarding reporting and investigating a suspected misappropriation of a resident’s medication. The facility’s written policy required immediate investigation when there was suspicion or reports of abuse, neglect, exploitation, or misappropriation of resident property, and mandated reporting all alleged violations to the Administrator, State Agency, Adult Protective Services, and other required agencies within specified timeframes. Despite these requirements, when empty tirzepatide (Mounjaro) pens belonging to a resident were discovered, the facility did not initiate an abuse/misappropriation investigation or report the incident to the State Agency or other required entities. The resident involved was cognitively intact and had a diagnosis of diabetes mellitus, with a physician’s order for weekly subcutaneous tirzepatide injections for Type 2 diabetes. The resident reported that on one occasion a nurse attempted to administer the weekly tirzepatide injection, but the syringe was empty, and when another syringe was obtained from the refrigerator, that syringe was also empty. The resident stated that she ultimately received her weekly injection, but it was administered two or three days late after medication was obtained from the pharmacy. She also reported that she had not previously experienced an issue with empty syringes when nurses attempted to give her the injection. Staff interviews confirmed that on the morning in question, the nurse assigned to the resident retrieved a tirzepatide pen from the refrigerator and found it already unlocked with the purple cap depressed, indicating it was empty. The Unit Manager, who was acting as DON at the time, verified that both remaining pens for this resident were empty by comparing them to another resident’s unused tirzepatide syringe. The Unit Manager notified the Administrator and Regional Clinical Manager and contacted the pharmacy, but she did not consider the possibility of misappropriation and did not initiate an investigation into how or why the pens were empty. The Administrator acknowledged being informed of the empty pens but did not seek further details, did not ensure an investigation was conducted, and did not recognize or report the situation as a potential misappropriation, despite the facility’s policy requiring such reporting and investigation.
Failure to Perform Hand Hygiene Between Glove Changes During Wound Care
Penalty
Summary
The deficiency involves the facility’s failure to follow its own hand hygiene policies during wound care for Resident #10. The facility’s Hand Hygiene and Basics of Hand Hygiene policies require staff to perform hand hygiene before applying and after removing PPE such as gloves, and before and after providing any type of care. During an observed wound care session, the Wound Nurse prepared supplies on a disinfected over-bed table with a protective barrier, washed her hands, and donned a gown and gloves before starting treatment. As the resident was positioned on her right hip to expose a left hip wound, the Wound Nurse removed the soiled dressing, removed her gloves, and then applied clean gloves without performing hand hygiene. She then cleansed the wound, applied skin prep, removed her gloves, sanitized her hands, and applied clean gloves before placing a foam dressing. After that, she again removed her gloves but did not perform hand hygiene before putting on another pair of clean gloves. The resident was then repositioned to expose sacral and right hip wounds. For the sacral wound, the Wound Nurse removed the dirty dressing, removed her gloves, and performed hand hygiene before donning clean gloves and cleansing the wound. She then removed her dirty gloves and again applied clean gloves without performing hand hygiene, applied soaked gauze and a foam dressing, then removed her gloves and performed hand hygiene before donning clean gloves. For the right hip wound, the Wound Nurse removed the dirty dressing, removed her gloves, and washed her hands before applying clean gloves and cleansing the wound. She then removed her dirty gloves and applied clean gloves without performing hand hygiene, applied soaked gauze and a foam dressing, and finally removed her gloves and performed hand hygiene. In interviews, the Wound Nurse acknowledged she did not realize she had failed to perform hand hygiene between some glove changes, stated she knew she was supposed to, and attributed the lapses to losing track due to multiple glove changes and being nervous under observation. The Infection Preventionist and Administrator both confirmed that facility policy and expectations require hand hygiene every time gloves are removed, regardless of visible soiling.
Failure to Accurately Code Oxygen Therapy on Admission MDS Assessment
Penalty
Summary
The facility failed to accurately code an admission Minimum Data Set (MDS) assessment for a resident who was receiving continuous oxygen therapy. The resident was admitted with diagnoses including atrial fibrillation, coronary artery disease, and pneumonia, and had physician orders and a baseline care plan indicating continuous oxygen at 2 liters per minute. The Medication Administration Record (MAR) confirmed that oxygen therapy was administered on all shifts. However, the admission MDS assessment did not reflect the use of oxygen therapy, despite the resident being cognitively intact and receiving the therapy. The MDS Nurse acknowledged the omission, attributing it to an oversight during a transition to a new electronic health record system.
Failure to Provide Ordered Continuous Oxygen During Resident Transport
Penalty
Summary
A resident with a history of coronary artery disease and pneumonia was admitted to the facility with a physician's order for continuous oxygen at 2 liters per minute. The resident's care plan and Medication Administration Record (MAR) reflected this order, and staff were expected to ensure the resident received continuous oxygen therapy. On the day in question, the resident became lethargic, confused, and was not eating or drinking, prompting the Nurse Practitioner to order transport to the emergency room (ER) for further evaluation. Multiple staff members, including nurses and nurse aides, were involved in preparing the resident for transport to the ER. However, none could definitively recall whether the resident was wearing or provided with oxygen during the transfer. The transportation aide, who drove the resident to the ER in a facility van, also could not confirm if oxygen was administered during the trip. Upon arrival at the ER, the resident was found to be unresponsive with an oxygen saturation of 81% on room air, and it was noted by ER staff that the resident was not receiving oxygen despite a standing order for continuous therapy. After oxygen was applied in the ER, the resident's oxygen saturation improved to 94%. The ER physician confirmed that the resident arrived without oxygen, despite the documented order for continuous use. Interviews with facility staff, including the Director of Nursing, indicated an expectation that residents with such orders would be transported with oxygen, but this was not implemented in this case. The failure to provide continuous oxygen as ordered during transport constituted a deficiency in the facility's provision of safe and appropriate respiratory care.
Failure to Verify Nurse Aide Competency Leads to Resident Injury
Penalty
Summary
The facility failed to verify the competency of a Nurse Aide (NA) in providing care for a dependent resident, leading to a serious incident. During incontinence care, the NA rolled the resident onto her side on an air mattress raised to waist height and then walked around the bed. The air mattress decompressed, causing the resident to roll off the bed and become wedged between the bed and the wall. The resident sustained multiple fractures and was admitted to the hospital for comfort care, where she later died. The investigation revealed that the NA had been hired without a completed competency checklist on file. The Staff Development Coordinator (SDC) and the Director of Nursing (DON) both acknowledged that competencies should have been verified before the NA took on assignments independently. The SDC admitted to not having a record of the NA's competencies and was unsure how this oversight occurred. The NA could not recall specific training or competencies completed upon hire. The facility's failure to ensure the NA's competencies were verified before allowing her to care for residents independently resulted in immediate jeopardy. The lack of a proper filing system for competency checklists, exacerbated by staff turnover and a change in ownership, contributed to the oversight. The incident highlighted deficiencies in the facility's processes for verifying and documenting staff competencies, which directly impacted resident safety.
Removal Plan
- NA #1 was counseled and re-educated on checking care guide at the beginning of each shift to determine level of assistance required, requesting assistance when appropriate, notifying charge nurse if another NA refuses to assist, not positioning a resident on their side on the edge of the bed and going to other side without another staff member present, use of two people assistance with air mattresses, and that two-person assistance must always be used for mechanical lifts.
- 100% of NAs and Nurses were in-serviced on facility practice regarding use of care guide for determining level of assistance with ADLs. Staff were instructed to check the care guide in the closet of each resident room to determine how many staff members needed to assist and ask for that assistance. If assistance was not available or refused, NAs were to report to the charge nurse.
- Staff were educated to never leave a resident lying on their side on the edge of the bed without a second staff present to prevent a fall from the bed.
- Staff were in-serviced that an air mattress might collapse if the resident was positioned on the edge of the mattress and therefore no resident could be left unattended to go to the other side.
- Staff were specifically educated that they must use two-person assistance for anyone using an air mattress.
- Staff were also educated that two-person assistance is always required on any type of mechanical lifts.
- Any staff member that was not able to be in-serviced will not be allowed to return to work until they have received the education.
- The SDC took NA#1 to a room and had her complete a return demonstration on providing care to a dependent resident in the bed. NA#1 was not allowed to return to work until all of this was completed.
- A skills checklist was completed with NA#1 and she was not allowed to return to work until this was completed.
- The DON educated the SDC that there must be a skills checklist on file for all new hires. No new hire will be allowed to begin work without a completed skills checklist.
- The facility will redo on hire skills checklists for all employees. No CNA or nurse will be allowed to return to work if they have not completed the on hire skills checklist.
- The Director of Nursing (DON) had the SDC sign an in-service form documenting that she was told to ensure the On Hire Skills Checklist is completed and filed on hire for all nursing staff.
- The SDC will place, for all new hires, the On Hire Skills Checklist in an employee file with the employee's name. This will be maintained in the SDC office. No employee will be allowed to begin work unless completed.
- A monitoring tool checklist, created by the Administrator, was implemented to track that the On Hire Skill Checklist was filed on hire and that annual training was provided with the date noted. The checklist will be maintained by the SDC.
Failure to Provide Adequate Assistance Leads to Resident Injury
Penalty
Summary
The facility failed to provide care in a safe manner, resulting in a serious accident involving a resident. The incident occurred when a Nurse Aide (NA) attempted to perform incontinence care on a resident who required two-person assistance due to impaired mobility and cognitive impairment. The resident was resting on an air mattress, and the NA rolled the resident onto her side without assistance, causing the air mattress to decompress. As a result, the resident rolled off the bed and became wedged between the bed and the wall, sustaining multiple fractures. The resident, who had a history of dementia, quadriplegia, and chronic respiratory failure, was severely cognitively impaired and dependent on staff for all activities of daily living, including bed mobility. Despite the care plan indicating the need for two-person assistance, the NA proceeded alone, citing the inability to locate another aide. The resident was subsequently found on the floor by the NA, who then alerted the nursing staff. The resident was transferred to the hospital, where she was diagnosed with multiple fractures and was deemed a poor surgical candidate due to her existing medical conditions. Interviews with staff revealed that the NA had been working a double shift and had not followed the care guide, which required two-person assistance for the resident. The NA admitted to attempting the care alone and acknowledged the mistake. The nursing staff, including the Night Shift Supervisor and Nurse #3, responded to the incident by assessing the resident and arranging for her transfer to the hospital. The resident was placed on comfort care and later died, with respiratory failure noted as the cause of death, potentially exacerbated by the pain from the fall.
Removal Plan
- NA #1 was suspended and re-educated on proper procedures, including checking care guides, requesting assistance, and using two-person assistance for air mattresses and mechanical lifts.
- NA #1 completed a demonstration of competency on providing care to a resident who is dependent for bed mobility.
- 100% of NAs and Nurses were in-serviced on facility practice regarding use of the care guide for determining level of assistance with ADLs.
- Staff were instructed to check the care guide in each resident room to determine assistance needed and to report if assistance was not available.
- Staff were educated not to leave a resident lying on their side on the edge of the bed without a second staff present.
- Staff were specifically educated to use two-person assistance for anyone using an air mattress or mechanical lifts.
- New hires and agency staff will receive training on utilizing the care guide and safe practices during orientation.
- Care guides are present in the closet of each resident to communicate special needs and are updated regularly.
- Nursing Admin will conduct skills checks on 10% of CNAs for proper use of two-person assistance.
- The QA committee will review results and modify actions as needed.
Failure to Resume Communal Dining Post-COVID and Hurricane
Penalty
Summary
The facility failed to honor a resident's choice for a communal dining experience, affecting a resident who was severely cognitively impaired and required supervision with eating. The resident's family member reported that the resident enjoyed dining with others and had better meal intakes in a communal setting. Observations confirmed that no meals were served in the main dining room over several days, despite the resident's preference for group activities as noted in their assessments. The cessation of communal dining began following a COVID-19 outbreak among staff, which was contained approximately three months prior. Although the outbreak was resolved, a subsequent hurricane impacted the area, leading to emergency preparedness measures and further delaying the resumption of communal dining. Interviews with facility staff, including the Registered Dietician, Dietary Manager, Director of Nursing, and Administrator, revealed awareness of the residents' preferences and the reasons for the delay, but communal dining had not yet resumed by the time of the survey.
Failure to Communicate Resolution of Resident Concerns
Penalty
Summary
The facility failed to effectively communicate its efforts to address concerns raised by residents during Resident Council meetings over a period of several months. The Resident Council meeting minutes from January to October 2024 documented recurring issues related to meal choices and dietary concerns. Despite these issues being consistently raised, there was no evidence that the facility communicated any actions taken to resolve these concerns back to the residents. This lack of communication led to residents feeling unheard and undervalued, as they repeatedly voiced the same issues without receiving feedback or updates on any resolutions. Interviews with residents revealed a shared sentiment of being ignored, as they expressed that their opinions did not seem to matter to the administration. The Activity Director and Social Worker, who attended the meetings, confirmed that while they documented the concerns and forwarded them to the appropriate department managers, they did not provide any feedback to the residents about the actions taken. This gap in communication was further highlighted by the Administrator, who acknowledged awareness of the repeated concerns but was unaware of the residents' feelings of neglect. The deficiency was primarily due to the facility's failure to establish a clear communication loop between the administration and the residents. Although the concerns were documented and presumably addressed internally, the lack of feedback to the residents perpetuated a cycle of dissatisfaction and repeated grievances. The facility's process did not include a mechanism for ensuring that residents were informed of the steps taken to address their concerns, leading to a breakdown in trust and communication between the residents and the facility's administration.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to adhere to its Enhanced Barrier Precautions (EBP) policy, which is designed to reduce the transmission of multidrug-resistant organisms. This deficiency was observed in the care of residents with indwelling medical devices and wounds. Specifically, Resident #126, who had a feeding tube, did not have appropriate EBP signage in their room, and staff, including Nurse #4, did not wear the required gown and gloves during high-contact care activities. The Infection Preventionist (IP) and Director of Nursing (DON) confirmed that EBP should have been implemented for Resident #126, but there was a lack of communication and signage to inform staff of the necessary precautions. Similarly, Resident #68, who had a pressure ulcer, was not placed on EBP, and staff did not wear the required personal protective equipment (PPE) during care. The IP stated that the wound was not large enough to warrant EBP, despite the facility's policy indicating that any wound care should involve EBP. The DON also confirmed that EBP should be in place for residents with wounds, but there was a misunderstanding regarding the criteria for implementing these precautions. For Resident #49, who had a stage 3 pressure ulcer, the IP Nurse and Wound Care Physician Assistant failed to don gowns during wound care, despite the presence of EBP signage instructing them to do so. The IP Nurse cited advice from NC SPICE that gowns were not necessary if the wound did not have drainage, although this was not consistent with the facility's policy. The Administrator was unaware of the specific CMS guidance on EBP, indicating a gap in knowledge and adherence to infection control protocols.
Inadequate Training and Communication on Enhanced Barrier Precautions
Penalty
Summary
The facility failed to adhere to its infection control policy and procedures, specifically regarding the training and implementation of Enhanced Barrier Precautions (EBP). The policy required all staff to receive training on EBP upon hire and annually, and to be informed about which residents required EBP. However, a review of training attendance sheets revealed that four nursing staff members did not receive this education. Interviews with these staff members confirmed their lack of familiarity with EBP, and they were not informed about residents requiring EBP, particularly those with indwelling medical devices. The Infection Preventionist (IP) and the Administrator acknowledged that staff were educated on EBP during orientation and an inservice, but confusion persisted among staff regarding the implementation of EBP. The IP noted that PPE was available on linen carts, but there was no consistent method to communicate which residents required EBP. The Administrator attributed the confusion to the complexity of different precaution types, which contributed to staff being unaware of EBP requirements.
Deficiency in Nurse Aide Training for Abuse and Dementia Care
Penalty
Summary
The facility failed to provide the required dementia and abuse training for six nurse aides, as revealed through record reviews and staff interviews. The nurse aides, hired between 1992 and 2024, did not have documented training in abuse prevention or dementia care for the period from November 2023 to November 2024. Additionally, one nurse aide lacked documented skills competencies. This deficiency was identified during a review of the education records maintained by the Staff Development Coordinator (SDC). Interviews with the SDC and the Director of Nursing (DON) highlighted a lack of clarity and communication regarding the training responsibilities. The SDC, who assumed the role in March 2024, was unaware of the missing training records and could not provide an explanation for the oversight. The DON acknowledged the turnover in the SDC position and expressed uncertainty about whether the SDC had been informed of their responsibilities, which included ensuring the completion of abuse and dementia training and conducting skills competencies during orientation and annually.
Failure to Obtain Provider Instructions for Medication Unavailability
Penalty
Summary
The facility failed to obtain additional instructions from the provider when semaglutide, a medication used to control blood sugar for a resident with Type 2 diabetes, was not available. The resident was admitted with a diagnosis of diabetes and was cognitively intact. An order was in place for the resident to receive semaglutide 0.5 mg subcutaneously once a week on Sundays. However, on the scheduled administration date, Nurse #2 documented that the medication was given, but upon reaching the resident's bedside, realized there was not enough medication in the pen to administer the correct dose. Nurse #2 contacted the pharmacy and was informed that it was not time for a refill. Despite this, Nurse #2 did not immediately inform the Nurse Supervisor or obtain further instructions from the provider. The resident reported being out of semaglutide since the previous week and confirmed not receiving the medication on the scheduled date. The Nurse Supervisor was only informed two days later, and upon learning of the situation, confirmed that Nurse #2 should have contacted the provider for further instructions. The Director of Nursing corroborated this expectation, indicating a lapse in protocol adherence.
Improper Air Mattress Settings for Pressure Ulcer Care
Penalty
Summary
The facility failed to appropriately adjust air mattress settings for two residents, leading to deficiencies in pressure ulcer care. Resident #68, who was cognitively impaired and had a pressure ulcer, was observed with an air mattress set to 240 pounds, despite weighing only 123.8 pounds. This setting was deemed inappropriate by the Wound Care Physician Assistant and Nurse #1, who both stated that the mattress should be set according to the resident's weight to provide effective pressure relief. The Maintenance Director initially set the mattress based on information from the hall nurse, but there was no process in place to ensure ongoing monitoring or adjustment of the settings. Similarly, Resident #20, who was moderately impaired in cognition and weighed 90 pounds, had a pressure-reducing mattress with settings fluctuating between 160 and 240 pounds, and later below 80 pounds. Nurse #4, responsible for the resident's care, did not adjust the settings and was unsure who was responsible for doing so. The Director of Nursing and the Administrator both acknowledged the lack of a process for monitoring mattress settings, with the Maintenance Director initially setting them based on the resident's weight. This lack of oversight and clear responsibility contributed to the improper settings for both residents' mattresses.
Failure to Maintain Clean Oxygen Concentrator
Penalty
Summary
The facility failed to maintain a clean and dust-free oxygen concentrator for a resident diagnosed with heart failure and COPD, who was receiving oxygen therapy. Observations revealed that the oxygen concentrator's filter was caked with gray dust around the intake and filter, indicating a lack of proper maintenance. This issue persisted over several days, as noted in observations made on different dates. Interviews with various staff members, including nurse aides, nurses, and central supply personnel, highlighted a lack of clarity regarding the responsibility for cleaning the oxygen concentrators. Nurse aides believed their role was limited to changing tubing, while nurses and central supply staff were unsure of their responsibilities. The central supply staff mentioned that department heads were supposed to ensure the concentrators were clean during daily rounds, but this was not effectively carried out. Further interviews with the medical records staff and the environmental services director confirmed that the oxygen concentrator remained dirty despite being part of routine checks. The environmental services director acknowledged that his staff was responsible for cleaning the concentrators but failed to do so. The director of nursing and the administrator both expected housekeeping staff to maintain the cleanliness of the concentrators, but this expectation was not met, leading to the deficiency.
Inaccurate Medication Administration Documentation
Penalty
Summary
The facility failed to ensure accurate medical records for a resident, identified as Resident #85, who was admitted with a diagnosis of diabetes. An order dated October 1, 2024, required the administration of semaglutide 0.5 mg subcutaneously once a week on Sundays. However, the November 2024 Medication Administration Record (MAR) inaccurately documented that the medication was administered on November 3, 2024, at 8:00 pm by Nurse #2. During an interview, Nurse #2 admitted to documenting the administration but realized at the resident's bedside that there was not enough medication in the pen to provide the correct dose. Nurse #2 failed to correct the MAR to indicate that the medication was not administered. The issue was brought to light when Resident #85 informed the Nurse Supervisor on November 5, 2024, that she had not received her semaglutide on November 3, 2024. The Nurse Supervisor confirmed the discrepancy with Nurse #2, who acknowledged the error in documentation. The Director of Nursing (DON) was also informed of the situation and confirmed that Nurse #2 should not have documented the medication as administered and should have corrected the MAR to reflect the missed dose.
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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