Matthews Health & Rehab Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Matthews, North Carolina.
- Location
- 600 Fullwood Lane, Matthews, North Carolina 28105
- CMS Provider Number
- 345103
- Inspections on file
- 19
- Latest survey
- April 16, 2026
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Matthews Health & Rehab Center during CMS and state inspections, most recent first.
A resident admitted with a MOST form, physician order, and advance directive all indicating DNR had this status omitted from the EHR banner, eMAR, and care plan. During a medication pass, the resident, who had severe cognitive impairment, was found unresponsive, and because the code status was not visible in the electronic systems used by staff, an RN initiated CPR and EMS was called. Another nurse located a code status binder showing DNR, at which point CPR was stopped and EMS was canceled. Interviews with the POA, physician, DON, unit manager, and social worker showed that although several staff were responsible for ensuring code status was entered and updated, the DNR status was never entered into the EHR banner, and the POA was not informed that CPR had been initiated.
A resident with diabetes and failure to thrive had physician-ordered labs that could not be collected as scheduled. Nursing staff did not notify the NP or physician of the missed lab draw, following facility protocol to reschedule for the next day. The NP was not informed of the delay and stated that immediate notification was necessary to determine if further interventions were needed. This lack of timely provider notification when labs were not obtained led to the deficiency.
The facility failed to implement infection control measures during a COVID-19 outbreak, leading to additional cases among staff and residents. The facility did not initiate contact tracing or broad-based testing until surveyor intervention and did not adhere to CDC guidelines for staff returning to work after testing positive. Observations revealed staff not consistently following PPE protocols, increasing the risk of transmission.
The facility failed to resolve grievances from Resident Council Meetings regarding unresponsive call lights and lack of evening snacks. Despite repeated documentation of these issues, no resolution was demonstrated. Residents felt ignored, and the Activity Director and Administrator were unaware of any improvements or resolutions, highlighting a lack of communication and follow-up.
A resident with a stage 4 sacral pressure ulcer did not receive the prescribed wound vac therapy over a weekend, as the facility staff used a wet-to-dry dressing instead. Despite the wound vac being functional, it was not utilized, and the physician was not informed of this deviation from the treatment plan. The facility's DON and Administrator acknowledged the failure to follow the treatment orders.
A resident with neuromuscular dysfunction of the bladder had an unsecured indwelling urinary catheter, despite the facility having a supply of securing devices. Observations showed the catheter tubing was not secured, and the resident was unaware of securing devices. Nursing staff were aware of securing devices for other residents but not for this resident. A nurse incorrectly stated there was no supply, although a device was found in a medication cart. The physician confirmed the necessity of securing devices, and the DON and Administrator acknowledged their availability.
The facility failed to provide evening snacks to residents in two halls, as nursing staff were unable to access the kitchen and snacks were not delivered. Residents reported not receiving snacks, and staff interviews confirmed the issue. The Dietary Manager was recently informed, but the Director of Nursing and Administrator were unaware.
The facility failed to ensure RN coverage for 8 consecutive hours on two specific days, as required. A review of staffing data revealed missing RN coverage on these days. The Administrator and DON claimed coverage was present and provided timecards for other dates, but failed to produce evidence for the days in question.
A facility failed to notify a resident and their family in writing about a hospital transfer and did not consistently inform the Ombudsman of resident transfers and discharges over several months. Interviews revealed confusion among staff about responsibilities for issuing transfer letters and communicating with the Ombudsman, following changes in administration.
A resident with lung disease was hospitalized for an upper respiratory infection and did not receive a required bed hold notice from the facility. Interviews with staff revealed confusion about who was responsible for issuing the notice, with the Administrator indicating that the social work department should handle it. This lack of clarity led to the deficiency.
A resident with cognitive impairments was physically assaulted by another resident who was cognitively intact, resulting in the victim being hospitalized. The incident occurred when the aggressor perceived the victim was going through his belongings. Despite staff intervention, the victim sustained a head injury and was transferred to another facility for further care.
A facility failed to report a resident-to-resident abuse incident to APS in a timely manner. The incident involved one resident punching another, causing injury and requiring hospital evaluation. Although the Facility Administrator was informed shortly after the event, APS was not notified immediately due to a misunderstanding of the screening criteria.
Failure to Accurately Reflect DNR Status in Electronic Record Leading to Initiation of CPR
Penalty
Summary
The facility failed to ensure that a resident’s advance directive and DNR status were consistently and accurately entered and displayed throughout the electronic medical record. The resident was admitted with a Medical Orders for Scope of Treatment (MOST) form and a physician’s order indicating a Do Not Resuscitate (DNR) status, and the advance directive documentation also reflected DNR. However, the electronic health record (EHR) face sheet banner, which is used to display key resident information including code status, did not show either Full Code or DNR for this resident. The resident’s care plan contained no documentation of an advance directive, and the code status was not available in the electronic Medication Administration Record (eMAR), which staff use to review treatment information. The resident had severe cognitive impairment per the 5‑day MDS assessment and was therefore not able to communicate wishes at the time of the incident. During a medication pass at approximately 10:00 AM, a nurse found the resident unresponsive. Because the code status was not visible in the EHR banner or eMAR, the nurse initiated CPR and called for assistance. Another nurse went to the nurse’s station to locate the code status binder and identified that the resident had a DNR order. CPR, which had been performed for less than one minute with approximately 25 chest compressions, was then discontinued, and EMS, which had been contacted, was later canceled once the DNR status was confirmed. Interviews revealed that multiple staff members had roles related to ensuring accurate code status documentation but that the resident’s DNR status had not been entered into the EHR banner or reflected in the care plan. The unit manager stated that nursing staff were responsible for entering admission orders and updating the banner to show Full Code or DNR, and indicated that a former ADON who worked with the family at admission may have missed updating the banner. The DON stated that all nursing staff were responsible for updating and entering code status in the banner and that each resident should have an advance directive status ordered upon admission. The physician confirmed the resident had a DNR order upon admission initiated by another provider per the POA. The POA reported that the resident’s wishes were for DNR and that he was not informed that CPR had been initiated.
Failure to Notify Provider of Unsuccessful Lab Collection
Penalty
Summary
The facility failed to notify the physician or Nurse Practitioner (NP) when ordered laboratory services could not be obtained for a resident. The resident was admitted with diagnoses including diabetes mellitus type II and adult failure to thrive. A physician's order was placed for a comprehensive metabolic panel (CMP) and a complete blood count (CBC) to be collected the following morning. However, when the phlebotomist attempted to collect the blood sample, they were unsuccessful in obtaining a specimen. Nurse #1 stated that it was standard practice for the laboratory to reschedule the collection for the next day and did not notify the NP or Medical Director about the missed lab collection, as the labs were ordered on a routine basis rather than as a stat order. The NP, upon interview, indicated that he was not informed that the labs were not obtained and emphasized that nursing staff should have notified him so he could determine if further interventions were necessary. The Medical Director also stated that the decision to notify would rest with the NP who ordered the labs. The Director of Nursing (DON) and the Administrator both stated that facility protocol was to reschedule lab work if collection was unsuccessful and believed staff followed this protocol. However, the NP clarified to the DON that immediate notification to providers is necessary if labs are delayed or not drawn, especially to ensure proper follow-up. The lack of timely notification to the provider when the labs were not obtained constituted the deficiency identified during the survey.
Failure to Implement Infection Control Measures During COVID-19 Outbreak
Penalty
Summary
The facility failed to implement its infection control policy and procedures in accordance with current CDC guidance during a COVID-19 outbreak. The outbreak began when two staff members tested positive for COVID-19, but the facility did not initiate contact tracing or broad-based testing for staff and residents until surveyor intervention. This delay in testing led to additional cases among staff and residents, with a total of nine staff members and seven residents testing positive before broad-based testing was implemented. The facility also failed to implement staff source control measures and did not ensure that staff wore the required personal protective equipment (PPE) when entering rooms under transmission-based precautions. The facility did not adhere to CDC guidelines for staff returning to work after testing positive for COVID-19. Several staff members returned to work without obtaining a negative COVID-19 test, contrary to CDC recommendations. The Infection Preventionist (IP) was unaware of the correct return-to-work criteria, leading to staff returning to work prematurely, potentially increasing the risk of further transmission within the facility. The facility's failure to follow these guidelines contributed to the continued spread of COVID-19 among residents and staff. Observations during the survey revealed that staff did not consistently follow PPE protocols. Nursing assistants were observed entering rooms of COVID-positive residents without wearing the appropriate PPE, such as gowns, gloves, and eye protection. Additionally, a nurse was observed not wearing a mask for source control while administering medications. These lapses in infection control practices further increased the likelihood of COVID-19 transmission within the facility.
Unresolved Resident Council Grievances
Penalty
Summary
The facility failed to address and resolve grievances raised during Resident Council Meetings over a period of several months. Specifically, the Resident Council repeatedly expressed concerns about nursing staff not responding to call lights in a timely manner and the lack of snacks being provided in the evening. These issues were documented in the meeting minutes from August to December, yet the facility did not demonstrate any response or resolution to these grievances. Interviews with residents confirmed that these concerns remained unaddressed, and they felt that the staff did not care about their ongoing issues. The Activity Director acknowledged that concerns were raised during stand-up meetings and with department heads, but there was no documentation to show that these issues were resolved. The Administrator was unaware that grievances from the Resident Council meetings were not being completed and resolved, despite expecting that concerns would be addressed and documented. This lack of communication and follow-up led to the ongoing dissatisfaction and unresolved grievances among the residents.
Failure to Maintain Wound Vac Therapy for Resident with Stage 4 Pressure Ulcer
Penalty
Summary
The facility failed to maintain proper wound care for a resident with a stage 4 sacral pressure ulcer, as ordered by the physician. The resident, who was admitted with a chronic sacral decubitus, type 2 diabetes, and peripheral artery disease, had a wound vac therapy order to be changed on Monday, Wednesday, and Friday. However, the wound vac was not used over the weekend, and instead, a wet-to-dry dressing was applied, which was not in accordance with the physician's orders. Observations and interviews revealed that the wound vac machine was not in use from Saturday to Monday, despite being in proper working order. Nurse #1 applied a wet-to-dry dressing on Saturday and reinforced it on Sunday, following instructions from her supervisor, even though the wound vac was not broken. The Treatment Nurse confirmed that the wound vac was functional and that the wet-to-dry dressing was not an acceptable treatment for the resident's condition. The physician was not informed of the deviation from the prescribed treatment and stated that the wet-to-dry dressing was inappropriate due to the high risk of infection. The Director of Nursing and the Administrator acknowledged that the treatment orders were not followed as written, indicating a lapse in communication and adherence to medical directives within the facility.
Failure to Secure Indwelling Urinary Catheter
Penalty
Summary
The facility failed to secure the indwelling urinary catheter for a resident with neuromuscular dysfunction of the bladder, which was necessary to reduce tension and prevent injury. The resident was admitted with a physician's order for an indwelling urinary catheter but lacked an order for a securing device. Observations over several days revealed that the catheter tubing was not secured, and the resident was unaware of what a securing device looked like. The care plan for the resident included goals to reduce the risk of urinary tract infections but did not address the need for securing the catheter tubing. Interviews with nursing staff indicated that they were aware of securing devices for other residents but had not seen any for this particular resident. A nurse stated that the facility did not have a supply of securing devices, although one was found in a medication cart. The physician confirmed that securing devices should be used for all residents with indwelling catheters as a standard recommendation. The Director of Nursing and the Administrator acknowledged that the facility had a supply of securing devices and that nursing staff should utilize them.
Failure to Provide Evening Snacks to Residents
Penalty
Summary
The facility failed to have systems in place for providing evening snacks to residents in two of its halls, which affected residents who requested snacks outside of scheduled meal times. During a Resident Council Meeting, several residents reported that they had not been offered evening snacks by nursing staff, and when they requested snacks, they were informed that the staff could not access the kitchen or that no snacks were available. This issue had been reported to the Dietary Manager, but it persisted. Interviews with staff revealed that nursing staff were often unable to access the kitchen at night to retrieve snacks, and there were multiple occasions when snacks were not provided for distribution. A nurse aide working the second shift confirmed that residents had not received bedtime snacks on multiple days due to the kitchen staff's failure to deliver them and the nursing staff's inability to access the kitchen. The Dietary Manager acknowledged being recently informed of the issue and stated that snack bins were checked and stocked daily, suggesting that nursing staff were not offering snacks as needed. The Director of Nursing and the Administrator were unaware of the issue, although they expected snacks to always be available for residents.
Failure to Provide RN Coverage for 8 Consecutive Hours
Penalty
Summary
The facility failed to provide Registered Nurse (RN) coverage for 8 consecutive hours on two specific days, 4/20/24 and 4/21/24, as required. This deficiency was identified through a review of the Payroll Based Journal (PBJ) staffing data report from the Certification and Survey Provider Enhanced Report (CASPER) database, which showed missing RN coverage on these dates. During an interview, the Administrator and Director of Nursing claimed that RN coverage was present and attempted to provide timecard evidence. However, they could only produce timecards for 5/05/24 and 6/02/24, confirming RN coverage on those days, but failed to provide any documentation for 4/20/24 and 4/21/24. Despite further attempts to locate the necessary evidence, the Administrator was unable to provide additional timecard information to support RN coverage on the missing dates.
Failure to Notify Resident and Ombudsman of Transfers
Penalty
Summary
The facility failed to provide timely written notification to a resident and their family member regarding a transfer to the hospital. Specifically, a resident who was cognitively intact was transferred to the hospital for an upper respiratory infection and later readmitted to the facility. However, there was no documentation of a transfer letter being provided to the resident or their representative. Interviews with the social workers and the business office manager revealed uncertainty about who was responsible for issuing these letters, indicating a lack of clarity in the facility's procedures. Additionally, the facility did not consistently notify the Ombudsman of transfers and discharges over a three-month period. While discharge reports for August, September, and October were eventually sent in November, there was no record of reports being sent for January. The social worker indicated that the responsibility for communicating with the Ombudsman had shifted following changes in administration, but the process was not consistently followed. The Ombudsman confirmed the lack of timely communication, highlighting a breakdown in the facility's protocol for notifying relevant parties of resident transfers and discharges.
Failure to Provide Bed Hold Notice for Hospitalized Resident
Penalty
Summary
The facility failed to provide a bed hold notice for a resident who was hospitalized, which is a requirement when a resident is transferred to a hospital or takes therapeutic leave. The resident, who was cognitively intact and had a diagnosis of lung disease, was transferred to the hospital for an upper respiratory infection and later readmitted to the facility. Upon review of the resident's electronic medical record, it was found that no bed hold notice was provided, and the resident confirmed that he did not receive such a notice during his hospitalization. Interviews with facility staff, including two social workers and the Business Office Manager, revealed uncertainty about who was responsible for issuing bed hold notices. The Administrator acknowledged a change in the social work department and indicated that the social work team should be responsible for providing the written bed hold notice. This lack of clarity and communication among staff members contributed to the failure to issue the required notice to the resident or their representative.
Resident-to-Resident Physical Abuse Incident
Penalty
Summary
The facility failed to protect a resident from physical abuse when another resident, who was cognitively intact, physically assaulted him. The incident occurred when the aggressor resident became upset after perceiving that the victim, who was severely cognitively impaired, was going through his belongings. The aggressor resident hit the victim three times on the back of the head and neck, resulting in the victim being transported to the emergency department for evaluation. A CT scan revealed a 4-millimeter hyperdense focus in the right frontal region of the victim's brain, which was questionable for focal hemorrhage, subarachnoid bleeding, or contusion. The victim, who was diagnosed with dementia and other cognitive impairments, was admitted to the facility with fluctuating inattention and disorganized thinking. Despite these impairments, the victim had clear speech and adequate vision and hearing. The aggressor resident, on the other hand, was cognitively intact and independent in self-care, using a manual wheelchair for mobility. The incident was reported by a nursing assistant who heard yelling and observed the aggressor resident hitting the victim. The nurse on duty intervened by restraining the aggressor and calling for emergency services. Interviews with staff and residents revealed that the aggressor resident had expressed concerns about the victim going through his clothes but had not filed any formal complaints. The facility's investigation found no prior indications that the aggressor resident would abuse others. The incident was reported to the police, who declined to cite the aggressor due to his physical condition and reliance on medical staff. The facility's failure to prevent this incident resulted in the victim being hospitalized and later transferred to another skilled nursing facility.
Failure to Report Resident-to-Resident Abuse to APS
Penalty
Summary
The facility failed to report an allegation of resident-to-resident abuse to Adult Protective Services (APS) in a timely manner. The incident involved two residents, where one resident was observed punching another resident, resulting in the injured resident being sent to the hospital for evaluation due to bleeding from the face. The altercation was witnessed by two nursing assistants and a nurse, who intervened to separate the residents and notified the Facility Administrator and local law enforcement. The Facility Administrator was informed of the incident shortly after it occurred but did not contact APS immediately, as he believed the screening criteria were not met. The initial report of the incident was submitted to the North Carolina Health Care Personnel Registry, but it did not include notification to APS. The Administrator later reported the incident to APS after realizing the potential for the injured resident not returning to the facility. The deficiency was identified during a review of facility-reported incidents, where it was found that APS was not notified as required. The failure to report the incident to APS promptly was a significant oversight in the facility's handling of the situation, as it involved a serious altercation between residents that resulted in injury and required hospital evaluation.
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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