Mount Olive Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Mount Olive, North Carolina.
- Location
- 228 Smith Chapel Road, Mount Olive, North Carolina 28365
- CMS Provider Number
- 345126
- Inspections on file
- 29
- Latest survey
- January 28, 2026
- Citations (last 12 mo.)
- 14 (1 serious)
Citation history
Health deficiencies cited at Mount Olive Center during CMS and state inspections, most recent first.
A cognitively intact resident used a nurse aide’s money transfer account to pay $120 for groceries, then accidentally sent an additional $300 intended for a relative. The resident promptly informed the aide of the mistake and repeatedly requested repayment, including partial amounts, but the aide did not return the funds and did not immediately report the situation to facility leadership. The resident later informed the Social Worker, who doubted the account and delayed notifying the Administrator, and an initial misappropriation report was not submitted to the State Agency as required.
A cognitively intact resident reported to a Social Worker that $300 had been inadvertently sent to a CNA via a money transfer app, with a promise of repayment that did not occur. The Social Worker, doubting the account, did not immediately notify the Administrator as required by the abuse and misappropriation policy, and the CNA continued to work assigned shifts during this period. The Administrator and DON later acknowledged that both the Social Worker and the CNA should have promptly reported the situation. When the Administrator eventually attempted to file the initial allegation report with the State Agency, an error in the email address prevented receipt, and this failure went unnoticed until identified by surveyors, leaving the allegation unreported to the State Agency for an extended period.
A resident with cognitive impairment and no opioid prescription was mistakenly given 60 mg of oxycodone intended for another patient after a nurse in training administered the medication without proper verification. The error occurred when a nurse handed the medication to the trainee, who failed to confirm the resident's identity according to policy. The incident was recognized and reported after administration, and the resident was monitored and treated for potential adverse effects.
A resident with chronic pain and fibromyalgia received oxycodone-acetaminophen as ordered, but staff failed to document the administration on the MAR, despite recording it on the narcotic sheet. Interviews confirmed this documentation error, and facility leadership stated that both records should be completed for narcotic administration.
A resident with vascular dementia and NPO status was repeatedly observed self-administering enteral feedings, using unidentified liquids in her g-tube, rummaging through trash for food and liquids, and disconnecting her tube feeding pump. Staff were aware of these behaviors but did not consistently assess the resident for self-administration, communicate with the physician or dietician, or implement effective interventions. The care plan relied on education and reminders, which were inconsistently provided, and there was a lack of supervision and monitoring, resulting in ongoing unsafe behaviors.
A resident with hypertension, heart failure, and orthostatic hypotension was repeatedly administered Coreg despite physician orders to hold the medication if systolic blood pressure was below 150 mmHg. Documentation and staff interviews revealed that the medication was given on numerous occasions when the resident's blood pressure was below the specified threshold, and staff were either unaware of or did not follow the hold parameters. The error was identified through MAR review, therapy notes, and pharmacy consultant findings, with no evidence that recommendations to address the issue were acted upon.
The facility did not maintain accurate medical records for three residents, including incorrect documentation of medication administration for a resident with hypertension and heart failure, and discrepancies between physician orders, MAR entries, and observed oxygen flow rates for two residents with respiratory conditions. Staff interviews confirmed that documentation did not reflect actual care provided, and the DON acknowledged the need for accurate verification and recording.
Two residents receiving antipsychotic medications did not receive ongoing Abnormal Involuntary Movement Scale (AIMS) assessments as required by protocol. Although care plans identified the need for regular AIMS testing due to the risk of complications from psychotropic medications, only a single assessment was documented for each resident. Staff interviews revealed that the EMR system may not have been set to trigger reminders for these assessments, and some staff were unaware of the requirement for ongoing AIMS evaluations.
Three residents did not receive supplemental oxygen as prescribed, with two receiving higher oxygen flow rates than ordered and one lacking required 'No Smoking - Oxygen in Use' signage. Staff interviews revealed inconsistent monitoring of oxygen concentrator settings and failure to ensure proper signage, despite clear physician orders and care plans.
The facility did not address or document pharmacist recommendations from monthly medication regimen reviews, resulting in missed assessments and medication administration errors for several residents with complex medical needs. Staff were unclear about their responsibilities for receiving, acting on, and storing these recommendations, and required documentation was often missing or unavailable.
Surveyors found that a medication cart was left unlocked and unattended, allowing access to various medications and supplies. An opened vial of insulin was discovered in a medication refrigerator without proper labeling, including missing open and discard dates and illegible resident information. Additionally, locked boxes containing refrigerated controlled drugs were not secured to permanent structures, making them removable from the medication rooms. Staff interviews confirmed these lapses in medication security and labeling.
A nurse failed to set an enteral feeding pump to the physician-ordered rate for a resident with a feeding tube, initially programming the formula and water flushes incorrectly. The error was discovered during observation and subsequently corrected after verification of the physician's order by the nurse and confirmation by the DON.
Two residents transferred to the hospital did not receive the required written notice of transfer/discharge, and the Ombudsman was not notified of these transfers. Staff interviews confirmed that while clinical documents were sent with the residents, the mandated notices were not provided, and social services staff did not complete or send the necessary notifications.
The facility did not consistently post accurate or complete daily nurse staffing information, with missing or outdated postings and incomplete details for several days. This occurred because the weekend Nurse Supervisor had not been assigned or trained to maintain the postings, and facility leadership was unclear about responsibility for this task.
A resident at an LTC facility did not receive the required bowel preparation for a scheduled colonoscopy and subsequent surgery, leading to the cancellation of both procedures. The facility failed to administer the bowel preparation as ordered, resulting in the resident undergoing unnecessary anesthesia and surgical preparation without the intended procedure being completed. Communication and documentation issues among staff contributed to the oversight.
Two residents assessed as unsafe smokers were found smoking unsupervised, leading to incidents where one resident's pants caught fire and another's bandage was burnt. Despite facility policies requiring supervision and secure storage of smoking materials, these protocols were not followed, allowing residents to access and use smoking materials unsupervised.
The facility failed to notify a physician of a significant change in condition for a resident who later expired from septic shock. Additionally, the facility did not inform the responsible party of a medication change for another resident, leading to a deficiency citation.
A resident in an LTC facility exhibited a rash and changes in mental status, but staff failed to communicate and act, delaying medical intervention. The resident was later found unresponsive and diagnosed with septic shock, leading to his death. Another resident with a head injury was moved without proper assessment.
Two residents in an LTC facility suffered injuries due to staff not following care plans. One resident, with osteoporosis, was improperly transferred without a mechanical lift, resulting in a femur fracture. Another resident, at risk for falls, was found on the floor with a fractured nose and no fall mats in place. These incidents highlight the facility's failure to adhere to care plans designed to prevent such injuries.
A resident with cognitive impairment and hearing loss did not receive necessary follow-up for malfunctioning hearing aids. Despite an audiologist's recommendation, the facility failed to act on warranty and repair information, leaving the resident without functional hearing aids. Staff were unaware of the issue until a surveyor highlighted it.
A resident with multiple health issues fell and sustained a head injury in a LTC facility. Due to insufficient staffing, the resident was moved back to bed by a nurse aide without an assessment. The facility was understaffed that night, with only five nurse aides on duty, leading to a delay in medical evaluation. The resident was later sent to the ER with significant facial trauma.
The facility failed to accurately document health status information for two residents. One resident's record inaccurately showed assessments after they had been transferred to a hospital, while another resident's record incorrectly maintained an order for a catheter that had been removed. Additionally, a rash observed on the second resident was not documented. These inaccuracies were acknowledged by the staff involved.
The facility failed to maintain the dignity and rights of residents, including unnecessary 1:1 observation for a resident cleared by an NP, a resident's urinal not being emptied before meals, and an uncovered urinary drainage bag visible from the hallway. These incidents highlight communication and procedural failures among staff.
The facility failed to ensure proper drying of kitchenware, as observed with wet meal trays and dinner plates stacked for reuse. The RD confirmed the need for air drying, and the Administrator acknowledged the oversight.
The facility's pest control program was ineffective, leading to fly infestations in the kitchen, resident rooms, and hallways. Despite recommendations from the pest control provider, fly trapping machines were not activated, and staff left doors open, allowing flies to enter. Residents and staff reported persistent fly issues, with residents using fly swatters and staff swatting flies during medication administration. The Maintenance Director implemented some measures, but fly activity remained significant.
Three residents were not involved in their care planning process due to administrative oversights. One resident, assessed as severely cognitively intact, was not invited to a care plan meeting, and documentation was missing. Another resident, also cognitively intact, was not present at his care plan meeting due to care being provided at the time, and his POA did not receive a message about the meeting. A third resident was not invited to a care plan meeting, and there was no documentation of such a meeting. The Social Service Director and Assistant Administrator acknowledged these oversights.
A resident was observed with a wander guard despite a physician's order to discontinue its use. The resident's care plan initially included the device due to an elopement risk, but an assessment later indicated no risk. Staff interviews revealed a lack of awareness about the need for the wander guard, and there was no documentation of its monitoring. The DON acknowledged the need for reassessment and a physician order.
A resident admitted with stroke-related conditions and a risk for aspiration did not receive ordered speech therapy services. Despite a physician's order for evaluation and treatment, the facility lacked documentation of a speech therapy screen or services. The absence of a speech therapist and the Rehabilitation Director's medical leave contributed to the oversight, with key staff unaware of the lapse.
The facility failed to post nurse staffing information at the beginning of each shift for several days. Observations revealed outdated postings, and interviews with the DON and Administrator indicated that responsibilities were not consistently fulfilled due to a new scheduler being in training and the DON assisting another building.
The facility did not ensure residents received their mail on Saturdays, affecting all residents. Interviews revealed that mail was only delivered if the Activities Director or front office staff were present. The Business Office Manager confirmed that mail was left at the front desk until Monday unless it appeared special. The Administrator stated the weekend receptionist was responsible for mail delivery, but this was not consistently done.
Failure to Protect Resident from Misappropriation of Personal Funds
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident’s right to be free from misappropriation of personal funds after a cognitively intact resident mistakenly transferred $300.00 to a nurse aide via a money transfer application. The resident, who had been admitted earlier and assessed as cognitively intact on a quarterly MDS, initially used the aide’s account to send $120.00 for groceries, which the aide purchased and delivered with a receipt. The following day, the resident accidentally transferred an additional $300.00 intended for a relative’s rent to the same aide’s account. When the aide next worked, the resident informed her of the mistake and requested the $300.00 be returned, explaining his hand coordination issues and shaky hands caused the error. The aide acknowledged to the resident that the $300.00 had already been withdrawn due to her overdrawn account and told him she would repay him when she received her paycheck. Despite the resident’s repeated requests, including attempts to negotiate partial repayment of $200.00 and then $150.00 through the money transfer application and in person, the aide did not return any of the funds during this period. The aide did not immediately notify the Director of Nursing or the Administrator when she became aware of the mistaken transfer, even though she had been educated not to take money from residents for any reason. The resident’s transaction history on the money transfer application corroborated the payments and multiple unfulfilled requests for repayment. The deficiency was further compounded when the resident reported the issue to the Social Worker, who did not act promptly on the allegation. The resident informed the Social Worker that he had inadvertently sent $300.00 to the aide and that the aide’s account was negative, with a promise of repayment after the aide’s paycheck. The Social Worker doubted the resident’s account and chose to wait to see if the aide would return the money, delaying notification to the Administrator until several days later. Additionally, as of a later date, the State Agency had not received an initial report from the facility regarding the allegation of misappropriation involving this resident and the aide, despite the incident meeting the criteria for such reporting.
Failure to Timely Report and Act on Alleged Misappropriation of Resident Funds
Penalty
Summary
The facility failed to implement its abuse, neglect, and misappropriation policy when an allegation of misappropriation of funds involving a cognitively intact resident was not immediately reported to the Administrator. The abuse policy required any staff who witnessed or became aware of suspected abuse, neglect, or misappropriation of patient property to report it immediately to a supervisor, who in turn was to immediately notify the Administrator or designee so that an investigation could be initiated within 24 hours and residents protected from further harm. The resident told the Social Worker that he had inadvertently sent $300 to a nurse aide via a money transfer application around Christmas, that the aide’s account was negative, and that she had promised to repay him after receiving her paycheck. The Social Worker doubted the truthfulness of the account and chose to wait to see if the funds would be returned instead of immediately reporting the allegation as required by policy. From the time the Social Worker was informed of the $300 transfer until several days later, the Administrator was not notified, and the nurse aide remained on the work schedule and had nurse aide assignments. The Administrator later confirmed that she was not informed of the situation until several days after the Social Worker first learned of it, and that the aide should have been removed from duty earlier to protect residents. The DON also stated that the aide should have immediately notified management when she became aware that the resident’s $300 had been transferred into her account. Additionally, when the Administrator attempted to submit the initial allegation report to the State Agency, she transposed letters in the State Agency’s email address, resulting in the report not being received, and she did not detect this failure until informed by the surveyor. As of a later survey date, the State Agency had not received the initial allegation report, and the facility’s corrective action plan inaccurately stated that the report had been sent on an earlier date.
Medication Error: Oxycodone Administered to Wrong Resident Due to Verification Failures
Penalty
Summary
A significant medication error occurred when a resident with diagnoses including Parkinson's disease, dementia, and palliative care, who was cognitively impaired and had no opioid prescription, was administered 60 mg of oxycodone intended for another resident. The error took place during a medication pass when a nurse in training (Nurse #1) was handed the medication by another nurse (Nurse #2), who had pulled the medication for the resident's roommate. Nurse #1 mistakenly believed the medication was for the resident and administered it without proper verification. Interviews and documentation revealed that Nurse #1 stated she thought she had verified the resident's name, but Nurse #2 reported not witnessing any confirmation of identity. Nurse #2 realized the error upon entering the room and immediately reported it. Both nurses notified the Unit Manager, who then informed the Nurse Practitioner and Director of Nursing. The resident was closely monitored and received naloxone and IV fluids after becoming sleepy, but remained stable throughout the monitoring period. The investigation identified that both nurses failed to follow the facility's medication administration policy, specifically the 5 rights of medication administration and the use of two resident identifiers. Additionally, it was found that the orientation and competency validation for the nurses involved was incomplete at the time of the incident, and there was inadequate supervision during the orientation process. The pharmacy consultant was not notified of the error, and the medication administration error was not discovered until after the event had occurred.
Failure to Accurately Document Narcotic Administration
Penalty
Summary
The facility failed to maintain accurate medical records for one resident with chronic pain syndrome and fibromyalgia. The resident had a physician's order for oxycodone-acetaminophen 5-325 mg to be administered every six hours as needed for pain. On a specific date, the resident's individual narcotic record sheet indicated that the medication was administered at two separate times. However, the December Medication Administration Record (MAR) did not reflect documentation of the medication being given at either time. During interviews, one nurse confirmed she had signed the narcotic record sheet but had not documented the administration on the MAR, acknowledging this as an error. The other nurse involved was no longer employed and could not be reached for comment. Both the DON and the Administrator confirmed that facility policy requires narcotics to be documented on both the narcotic sheet and the MAR when administered.
Failure to Assess and Supervise Resident with G-Tube Leading to Unsafe Self-Administration and Ingestion Behaviors
Penalty
Summary
The facility failed to assess a resident with vascular dementia, dysphagia, and NPO status for self-administration of enteral feedings and did not implement effective interventions after repeated observations of unsafe behaviors. The resident was observed multiple times by staff and surveyors self-administering tube feedings, using unidentified liquids in her gastrostomy tube, rummaging through trash for food and liquids, chewing and spitting out food, obtaining food as bingo prizes, and disconnecting herself from her g-tube pump during continuous feedings. Despite these behaviors, there was no documented assessment or physician order for self-administration of tube feedings, and the care plan interventions were limited to education and reminders, which were inconsistently provided and documented. Staff interviews revealed that the resident frequently disconnected her tube feeding, used items from the trash, and attempted to self-administer both water and tube feeding formula, sometimes using bottles she had taken from the trash or her room. Several staff members, including nurses and the NP, were aware of these behaviors but did not consistently communicate them to the physician, Registered Dietician, or other relevant team members. The Medical Director and Psychiatric NP were not made aware of the full extent of the resident's behaviors, and the Registered Dietician was not informed about deviations in the resident's tube feeding regimen. The Activities Director was also unaware of the resident's NPO status and provided food prizes for bingo, despite the resident's inability to swallow. Observations and record reviews indicated a lack of effective supervision and monitoring, as the resident was able to access and use potentially contaminated items for her tube feedings and was not prevented from obtaining or attempting to consume food and liquids orally. Documentation was inconsistent, and there was no system in place to ensure that all staff, including agency staff, were aware of and followed the resident's care plan. The facility's failure to assess the resident's capacity for self-administration and to implement and communicate effective interventions resulted in ongoing unsafe behaviors and placed the resident at risk.
Failure to Prevent Significant Medication Error Related to Blood Pressure Parameters
Penalty
Summary
A significant medication error occurred when a resident with a history of hypertension, heart failure, and orthostatic hypotension was administered Coreg (carvedilol) despite physician orders to hold the medication if the systolic blood pressure was less than 150 mmHg. The resident's blood pressure readings frequently fell below this threshold, yet Coreg was administered on numerous occasions as documented in the Medication Administration Records (MAR) for July, August, and September. The error was identified through record review, interviews with nursing staff, pharmacy consultant, nurse practitioner, and cardiologist, and was corroborated by therapy notes documenting episodes of dizziness and low blood pressure during therapy sessions. The resident's care plan included interventions to administer medications as ordered, assess for effectiveness, and report abnormalities to the physician. Despite these interventions, the MAR showed that Coreg was given when the resident's systolic blood pressure was below the ordered parameter on multiple dates. Interviews with nursing staff and medication aides revealed a lack of awareness or understanding of the hold parameters in the physician's order, with some staff admitting they did not read the full order or did not realize the medication should have been held. The Director of Nursing noted that the electronic MAR required scrolling to see the full order, which may have contributed to the oversight. Pharmacy consultant reviews also identified the error and documented that Coreg was administered contrary to the hold parameters, but there was no evidence that these recommendations were addressed by medical providers or nursing staff. The nurse practitioner and cardiologist were not aware that the medication had been administered outside of the prescribed parameters. The resident experienced symptoms consistent with orthostatic hypotension, including dizziness and low blood pressure during therapy, which were documented in therapy and nursing notes.
Inaccurate Documentation of Medication and Oxygen Administration
Penalty
Summary
The facility failed to maintain accurate and complete medical records for three residents regarding the administration of medications and oxygen therapy. For one resident with hypertension and heart failure, the Medication Administration Records (MAR) for July and August documented that Coreg was administered even when the resident's blood pressure was below the physician-ordered threshold of 150 mmHg. The nurse responsible for the documentation admitted that the records were incorrect and could not explain the discrepancies, confirming that the medication was not administered as recorded and that the MAR did not accurately reflect the resident's medication administration. Additionally, two residents with respiratory conditions requiring oxygen therapy had discrepancies between the physician's orders, the MAR, and actual observations. One resident with acute respiratory failure and asthma had a physician order for 3 liters per minute of oxygen, but was observed receiving 4 liters per minute, while the MAR reflected the ordered amount. Another resident with COPD and heart failure had a physician order for 2 liters per minute of oxygen, but was observed receiving 6 liters per minute, despite the MAR indicating the ordered amount. Staff interviews confirmed that the documentation did not match the observed oxygen settings, and the Director of Nursing acknowledged that staff should be verifying and documenting the correct oxygen flow rates each shift.
Failure to Complete Ongoing AIMS Assessments for Residents on Antipsychotics
Penalty
Summary
The facility failed to provide ongoing Abnormal Involuntary Movement Scale (AIMS) assessments for residents receiving antipsychotic medications, as required by protocol. For two residents with diagnoses including depression with psychosis and bipolar disorder, medical records showed that only one AIMS assessment was completed for each resident, with significant lapses in subsequent assessments. Care plans for both residents indicated a risk for complications related to psychotropic and antipsychotic medications and included interventions for AIMS testing per protocol, but these interventions were not consistently implemented. Interviews with facility staff, including the DON and the pharmacy consultant, confirmed that AIMS assessments were to be conducted every six months for residents on antipsychotics. However, the DON stated that the electronic medical record (EMR) system may not have been properly set to trigger reminders for these assessments, resulting in missed assessments. Unit management staff were unaware of the need for ongoing AIMS assessments for the affected residents, and the pharmacy consultant could not recall discussing the assessments with the DON. The administrator confirmed that the DON was responsible for ensuring completion of AIMS assessments.
Failure to Administer Oxygen as Prescribed and Post Required Oxygen Signage
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for three residents by not administering supplemental oxygen as prescribed by the physician and by failing to post required cautionary signage indicating oxygen use. For one resident with chronic obstructive pulmonary disease, although the care plan and physician orders specified oxygen at three liters per minute via nasal cannula, there was no 'No Smoking - Oxygen in Use' signage posted outside the resident's door. Multiple staff interviews confirmed that both nursing and respiratory therapy staff were responsible for ensuring signage was in place, but the signage was missing and not checked during rounds. Another resident with acute respiratory failure, severe persistent asthma, and hypoxemia had a physician order for oxygen at three liters per minute to maintain oxygen saturation above 90%. However, the resident was observed receiving oxygen at four liters per minute, and the medication aide on duty documented this higher setting but was unable to adjust the concentrator. The resident was capable of changing the setting independently. Staff interviews revealed that nursing staff were expected to check and set the oxygen concentrator according to physician orders every shift, but this was not consistently done. A third resident with COPD, altered mental status, and heart failure had a physician order for oxygen at two liters per minute via nasal cannula for hypoxia. Observations showed the resident receiving oxygen at six liters per minute, while the medication administration record indicated two liters per minute was documented. Nursing staff admitted they did not check the oxygen concentrator settings during their shifts, despite expectations from the DON and administration that these checks should occur every shift.
Failure to Address and Document Pharmacist Recommendations in Medication Regimen Reviews
Penalty
Summary
The facility failed to ensure that irregularities identified by the Consultant Pharmacist during monthly drug regimen reviews were addressed and that documentation of these reviews was maintained and readily available. Multiple residents receiving antipsychotic and other high-risk medications did not have required assessments, such as the Abnormal Involuntary Movement Scale (AIMS), completed at the recommended intervals. For example, one resident on antipsychotic medication had only one AIMS assessment on file, despite repeated pharmacist recommendations for ongoing assessments, and there was no evidence that these recommendations were acknowledged or acted upon by staff. Additionally, recommendations regarding medication administration timing, such as separating psyllium from other medications to avoid absorption issues, were not communicated or implemented, and staff were unaware of these recommendations. The report also documents that medication regimen review reports and pharmacy recommendations were not consistently maintained or accessible in the facility. In several cases, the facility was unable to provide copies of pharmacy recommendations for extended periods, and staff interviews revealed confusion about who was responsible for receiving, addressing, and storing these recommendations. The Director of Nursing (DON), Nurse Practitioner (NP), and Administrator each described different processes and responsibilities, leading to a lack of clarity and follow-through. In some instances, recommendations to hold medications based on clinical parameters, such as blood pressure, were not followed, and there was no documentation that these issues were addressed by nursing or medical staff. Residents affected by these deficiencies included individuals with complex medical histories, such as those with bipolar disorder, anxiety, depression, hypertension, and heart failure, who were prescribed multiple medications requiring careful monitoring. The lack of proper documentation, communication, and follow-up on pharmacist recommendations resulted in repeated medication administration errors and missed assessments. Staff interviews confirmed that recommendations were often not received, acknowledged, or acted upon, and there was no established system for ensuring that pharmacy recommendations were addressed and retained in the residents' records.
Medication Storage and Labeling Deficiencies
Penalty
Summary
Surveyors identified multiple deficiencies related to the storage and labeling of medications. One medication cart was observed unlocked and unattended at a nursing station, with several residents and staff passing by. The lock on the cart was only partially engaged, allowing access to over-the-counter medications, respiratory inhalers, ear and eye medications, diabetic supplies, and a locked narcotic box. The nurse responsible for the cart admitted to not fully locking it to allow nurse aides access to blood pressure supplies, and both the Regional Nurse Consultant and Director of Nursing confirmed that the cart should have been completely locked when unattended. In a separate incident, an opened vial of Lispro insulin was found in a medication refrigerator without an open date, discard date, or legible resident information on the label. The manufacturer’s guidelines require the insulin to be discarded 28 days after opening, and both the unit manager and Director of Nursing acknowledged that the vial should have been properly labeled and not used for any resident. The vial was subsequently discarded after being identified as non-compliant. Additionally, locked black boxes used to store refrigerated controlled medications were found unsecured to permanent structures in two medication rooms. These black boxes, although locked and kept in locked medication rooms, could be removed from the refrigerators, which themselves were not locked. Staff interviews confirmed that the black boxes were not secured to prevent removal, and the Director of Nursing stated that the controlled medications were considered secure due to being behind two locking mechanisms, despite the lack of physical attachment to a permanent structure.
Failure to Administer Enteral Feeding at Physician-Ordered Rate
Penalty
Summary
A deficiency occurred when a nurse failed to administer enteral feeding formula at the correct rate as ordered by the physician for a resident with dysphagia, gastrostomy for enteral feedings, malnutrition, and vascular dementia. The resident's physician order specified continuous enteral feeding via a pump at 130 ml per hour for 12 hours overnight, with water flushes of 50 ml every 4 hours. During an observation, the nurse programmed the feeding pump incorrectly, setting the formula to infuse at 50 ml per hour and the water flushes at 130 ml every 4 hours, contrary to the physician's orders. The error was identified when the nurse was asked to verify the physician's order and realized the settings were incorrect. The nurse then re-entered the resident's room and adjusted the pump to the correct settings as per the physician's order. The Director of Nursing confirmed that the enteral feeding pump should have been set according to the physician's instructions. The deficiency was based on the failure to follow the prescribed enteral feeding and water flush rates for the resident.
Failure to Provide Required Transfer/Discharge Notices and Ombudsman Notification
Penalty
Summary
The facility failed to provide written notice of transfer or discharge to residents and to notify the Ombudsman when residents were transferred from the facility to the hospital. Specifically, two residents who were hospitalized did not receive the required written notice of transfer/discharge, and there was no evidence that the Ombudsman was informed of these transfers. Record reviews showed that neither resident had documentation of receiving the notice, and interviews with the residents confirmed they did not recall receiving such notification. One resident was cognitively intact at the time of transfer, while the other was severely cognitively impaired. Staff interviews revealed that nursing staff sent clinical documents such as face sheets, order summaries, and medication administration records with the residents during transfer, but did not include the required notice of transfer. Social services staff, who were responsible for providing these notices, confirmed that the notices were not completed or sent for the two residents in question. Additionally, the Ombudsman was not notified of the transfers, as the process relied on having a copy of the notice, which was not available for these cases.
Failure to Accurately Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to post accurate and complete daily nurse staffing information for three out of six days reviewed. On one occasion, the posted staffing information was outdated, and on another, the posting was incomplete, lacking details for certain shifts and missing required information such as census and licensed nurse staffing. For one day, there was no staffing posting at all. Interviews revealed that the weekend Nurse Supervisor, who was supposed to be responsible for maintaining the daily staffing postings on weekends, had not been assigned or trained to perform this duty, resulting in the postings not being completed. The Director of Nurses and the Administrator both indicated uncertainty regarding who was responsible for the postings on weekends.
Failure to Administer Bowel Preparation Leads to Procedure Cancellations
Penalty
Summary
The facility failed to administer the necessary bowel preparation for a resident on two separate occasions, leading to the cancellation of medical procedures. The first incident occurred when the resident was scheduled for a colonoscopy. Despite having clear orders for bowel preparation, the medication administration record showed that the preparation was not administered as required. The resident consumed a soda and did not complete the bowel preparation, resulting in the cancellation of the colonoscopy. The second incident involved a scheduled surgery for a limited sigmoid colon resection. The resident was supposed to undergo surgery to remove a suspicious colon polyp. However, the surgery was aborted after the surgeon discovered that the colon was full of stool, indicating that the bowel preparation had not been completed. The facility did not have any record of receiving bowel preparation orders from the surgeon's office, and there was a lack of follow-up to ensure the resident received the necessary instructions. Interviews with staff revealed a breakdown in communication and documentation. The Nurse Practitioner and other staff members did not verify or follow up on the bowel preparation orders, and there was confusion about whether the resident received the necessary instructions. The facility's failure to administer the bowel preparation as ordered resulted in the resident undergoing unnecessary anesthesia and surgical preparation without the intended procedure being completed.
Inadequate Supervision of Unsafe Smokers
Penalty
Summary
The facility failed to ensure adequate supervision for two residents who were assessed as unsafe smokers, leading to incidents where they were found smoking unsupervised. Resident #1, diagnosed with Huntington's disease and ataxia, was identified as requiring supervision while smoking due to unsafe habits, including sharing and selling smoking materials. Despite this, he was found alone in the smoking area with his pants on fire, having inappropriately extinguished a cigarette with his shoe. Staff discovered approximately 30 lighters in his room, indicating he had access to smoking materials despite the facility's policy that these should be kept at the nurses' station. Resident #2, who had chronic obstructive pulmonary disease and no fingers on either hand, was also identified as an unsafe smoker requiring supervision. However, he was found with a burnt bandage on his hand after smoking unsupervised. Despite being reminded of the smoking policy, Resident #2 claimed he was outside with staff, although no staff were present to supervise him at the time of the incident. The facility's policy required that smoking materials be stored at the nurses' station and that residents be supervised while smoking, but these protocols were not followed. Both incidents highlight a failure in the facility's supervision and management of smoking materials for residents assessed as unsafe smokers. The lack of adherence to the smoking policy and inadequate supervision allowed residents to access and use smoking materials unsupervised, leading to potentially dangerous situations. The facility's staff were either unaware of the residents' smoking status or failed to enforce the necessary precautions, resulting in these deficiencies.
Failure to Notify Physician and Responsible Party of Changes in Condition and Medication
Penalty
Summary
The facility failed to notify the physician of a significant change in condition for a resident, identified as Resident #13, who was observed by nurse aides to be in an altered mental state, not eating, and having a rash on multiple areas of his body. Despite these observations, the physician was not notified, and the resident was not assessed for further medical intervention. The following day, the resident was found to be in septic shock and was transferred to the hospital, where he later expired. The lack of communication and failure to act on the resident's change in condition contributed to the deficiency. Additionally, the facility failed to notify the responsible party of a medication change for another resident, identified as Resident #6. The resident's narcotic medication was changed from Oxycodone ER to Morphine ER without informing the responsible party. This oversight was discovered only after the responsible party inquired about the resident's increased drowsiness. The failure to communicate medication changes to the responsible party was another aspect of the deficiency. The report highlights the facility's failure to have effective systems in place for notifying physicians and responsible parties of significant changes in residents' conditions and treatment orders. This lack of communication and documentation led to immediate jeopardy for Resident #13 and a deficiency citation for the facility.
Failure to Recognize and Act on Resident's Change in Condition
Penalty
Summary
The facility failed to ensure proper communication and action among staff and with the physician, resulting in a resident not receiving timely medical services during an emergency situation. A resident exhibited a rash, described by staff as a 'death rash,' along with changes in mental status and eating habits. Despite these observations, no immediate action was taken to provide medical care. The following morning, the resident was found unresponsive with mottled skin and was transferred to the hospital, where he was diagnosed with septic shock and later expired. The resident had a complex medical history, including severe malnutrition, chronic alcoholism, and multiple health conditions such as emphysema and an abdominal aortic aneurysm. Upon admission to the facility, he was noted to be cognitively intact and was receiving rehabilitation. However, staff failed to recognize the significance of the rash and changes in the resident's condition, leading to a delay in emergency medical intervention. Additionally, the facility failed to assess another resident who sustained a head injury following a fall before moving them. This lack of adherence to professional standards of practice was identified for two of the five residents reviewed. The facility's inaction and lack of communication among staff contributed to the adverse outcomes observed in these cases.
Failure to Follow Care Plans Leads to Resident Injuries
Penalty
Summary
The facility failed to ensure that staff provided transfer assistance as care planned for a resident with osteoporosis, leading to a fracture. The resident, who was severely cognitively impaired and dependent on staff for mobility, was supposed to be transferred using a mechanical lift with a full body sling. However, staff members were found to have been transferring the resident by standing and pivoting, contrary to the care plan. This improper transfer method likely contributed to the resident's acute fracture of the left distal femur, which was discovered after the resident was sent to the hospital for evaluation of increased knee pain. Another resident, with a history of falls and osteoporosis, was found on the floor with a large hematoma and a fractured nose, indicating a failure to ensure fall mats were in place as per the care plan. The resident, who was totally dependent on staff for mobility and had contractures, was supposed to have fall mats on both sides of the bed. However, at the time of the fall, no fall mats were present, and the resident sustained significant facial trauma. The incident occurred when a CNA found the resident on the floor during rounds, and the resident was subsequently sent to the hospital for evaluation. The deficiencies in care for both residents highlight a lack of adherence to established care plans, which were designed to prevent injuries due to the residents' medical conditions. The failure to use a mechanical lift for transfers and the absence of fall mats as required by the care plans directly contributed to the injuries sustained by the residents. These incidents underscore the importance of following individualized care plans to ensure resident safety and prevent accidents.
Failure to Address Resident's Hearing Aid Needs
Penalty
Summary
The facility failed to follow up on an audiologist's recommendation regarding a resident's hearing aids, resulting in a deficiency. The resident, who was admitted with diagnoses including stroke and dementia, was cognitively impaired and had impaired hearing. The resident's care plan noted that the hearing aids were not working, but no interventions were documented to address the malfunctioning devices. An audiology report indicated that one hearing aid was lost and the other was damaged, with a recommendation to follow up on warranty and repair information. However, there was no documentation of any follow-up actions taken by the facility. Interviews with the resident's Responsible Party (RP) and facility staff revealed a lack of communication and awareness regarding the resident's hearing aid issues. The RP reported that the facility was supposed to check on obtaining new hearing aids, but no progress had been made. The Assistant Director of Nursing (ADON) and the facility's social worker were unaware of the necessary steps to address the missing and damaged hearing aids. The Administrator and Director of Nursing were also unaware of the problem until it was brought to their attention by a surveyor. The audiologist's consult had been filed in the electronic record without notifying the staff, leading to the oversight.
Insufficient Staffing Leads to Delayed Assessment After Resident Fall
Penalty
Summary
The facility failed to provide sufficient staff to ensure a resident received an assessment prior to being moved following a fall with a head injury. The incident involved a resident with multiple diagnoses, including stroke, heart disease, osteoporosis, and dementia, who was found on the floor with a head injury and skin tears. The resident was discovered by a nurse aide who, due to a lack of available staff, moved the resident back to bed without an assessment. The nurse aide was unable to find immediate assistance, as there were only five nurse aides on duty that night due to call-outs. The medication aide assigned to the resident was busy administering medications to other residents and was not present at the time of the fall. The nurse covering for the medication aide was also occupied with other duties and did not assess the resident until later. The nurse documented the fall and notified the provider, who ordered the resident to be sent to the emergency room. The emergency room records indicated significant facial trauma, including a nasal bone fracture, but no other traumatic injuries. The staffing sheets revealed that the facility was understaffed on the night of the incident, with two nurse aides assigned to the resident's station. The night shift nursing supervisor was also serving as a floor nurse and was occupied with another resident who required continuous monitoring. Interviews with staff indicated that the lack of sufficient staffing contributed to the delay in assessing the resident after the fall, as the available staff were overwhelmed with their responsibilities.
Inaccurate Documentation of Resident Health Status
Penalty
Summary
The facility failed to accurately document health status information in the medical records of two residents, leading to deficiencies in record-keeping. For Resident #3, the documentation indicated that the resident was assessed at the facility at a time when they had already been transferred to the hospital. The skilled nursing evaluation recorded vital signs and health assessments that could not have been conducted as the resident was not present at the facility. This discrepancy was acknowledged by Nurse #11, who admitted the documentation was made in error, as she was a travel nurse and did not recall the resident. For Resident #13, the medical record inaccurately maintained an order for a catheter that had been removed and not reinserted prior to the resident's discharge. Despite the resident voiding without a catheter, the electronic medical record still reflected the presence of a catheter. Additionally, Nurse #8's documentation failed to mention a rash observed on the resident and inaccurately noted the presence of a catheter. The Nurse Practitioner relied on these nursing notes for evaluating residents, highlighting the importance of accurate and complete documentation.
Failure to Maintain Resident Dignity and Rights
Penalty
Summary
The facility failed to uphold the dignity and rights of several residents, as evidenced by multiple incidents. One resident, who had been admitted with a history of stroke and depression, was placed on a 1:1 observation following a threat to self-harm after receiving a 30-day discharge notice. Despite being cleared by a Nurse Practitioner the following day, the facility continued the 1:1 observation for 30 days, which the resident felt was punitive and retaliatory. The resident expressed frustration and a lack of privacy, and the Ombudsman confirmed the resident's increased depression due to the observation. The facility's administration and medical staff failed to communicate effectively, resulting in the unnecessary continuation of the observation. Another resident, who was cognitively intact and required assistance for mobility, experienced a lack of dignity when a half-full urinal was left on their bedrail during meal times. The resident reported that the urinal was not emptied as often as needed, leading to an unpleasant smell during meals. Staff interviews revealed a lack of awareness and responsibility for ensuring the urinal was emptied before meal delivery, indicating a breakdown in communication and procedure adherence among the facility staff. A third resident, who was severely cognitively impaired and had an indwelling urinary catheter, was observed with an uncovered urinary drainage bag visible from the hallway. This lack of privacy was noted over several days, and staff interviews revealed uncertainty about the requirement for privacy covers for residents confined to bed. The Director of Nursing confirmed that catheter bags should be covered for all residents, highlighting a failure in maintaining resident dignity and privacy.
Improper Drying of Kitchenware
Penalty
Summary
The facility failed to adhere to proper food safety protocols by not allowing cooking pans and dome lids to completely dry before stacking them for reuse. During an observation of the kitchen, it was noted that thirty-three meal trays were stacked wet and ready for reuse on a cart next to the tray line. The Registered Dietitian (RD) confirmed that the meal trays should be air dried before meal service and instructed the kitchen staff to rewash and air dry the trays. In a subsequent observation, twenty dinner plates were also found stacked wet and ready for reuse. The RD acknowledged that the plates should have been air dried. The Administrator later confirmed that the kitchen staff should have ensured the meal trays and dinner plates were air dried.
Ineffective Pest Control Program Leads to Fly Infestation
Penalty
Summary
The facility failed to maintain an effective pest control program, as evidenced by fly activity observed in the kitchen, resident rooms, and hallways. The pest control service provider had made recommendations to prevent recurring pest activity, including repairing cracks and sealing gaps, but these were not fully implemented. Observations revealed that fly trapping machines in the kitchen were not turned on, and there was an open cereal bag in the dry storage area, which could attract pests. Additionally, the kitchen staff left the back door open, which could allow flies to enter. Multiple residents reported issues with flies in their rooms. Resident #113 and Resident #24, both cognitively intact, were observed with fly swatters and reported having to kill flies frequently. During medication administration, flies were observed around food and medication carts, and staff were seen swatting at them. Nurse #4, who had been working at the facility for a few weeks, noted that the flies had been a persistent issue since she started. The Maintenance Director had installed blue lights in the halls and air curtains at entrance doors, but issues such as worn-out gaskets on lobby doors may have allowed flies to enter. Despite these efforts, staff and residents continued to report significant fly activity. The Administrator acknowledged the need to relocate fly trapping machines due to a lack of nearby outlets and believed the pest control program was effective due to perceived improvements.
Failure to Involve Residents in Care Planning
Penalty
Summary
The facility failed to involve residents and their representatives in the care planning process, as evidenced by the cases of three residents. Resident #69, who was assessed as severely cognitively intact, was not invited to participate in the care plan meeting after admission. The Assistant Administrator, who was covering social services duties at the time, could not find documentation of the care plan meeting, attributing the oversight to human error. Both the Director of Nursing and the Administrator confirmed that the resident and her representative should have been invited to the meeting. Resident #125, who was cognitively intact, also did not participate in his care plan meeting. The Social Service Director noted that the resident was unable to attend due to care being provided at the time, and a message was reportedly left for the resident's Power of Attorney, who later stated she did not receive any such message. The Social Service Director admitted she could have waited to conduct the meeting after care was completed but did not, and she was new to the position and still learning the process. Resident #108, also cognitively intact, was not invited to a care plan meeting, and there was no documentation of such a meeting in the resident's electronic medical record. The Social Worker Director, who started after the resident's admission, and the Assistant Administrator, who was responsible for scheduling meetings at the time, both confirmed that there was no record of an interdisciplinary care plan meeting being scheduled or held for the resident. The Social Worker Director acknowledged that the resident and her representative should have been invited to a care plan meeting.
Failure to Discontinue Wander Guard as Ordered
Penalty
Summary
The facility failed to discontinue the use of a wander guard for a resident based on a physician's order and an elopement assessment. The resident, who was admitted with diagnoses including hypertension and heart failure, was observed with a wander guard on the left ankle despite a physician's order to discontinue its use. The resident's care plan initially included the use of a wander guard due to a risk for elopement, but an elopement evaluation later indicated the resident was not at risk. There was no current physician order for the wander guard, and no documentation of monitoring its use was found in the resident's records. Interviews with staff revealed a lack of awareness and understanding regarding the resident's need for the wander guard. The resident expressed discomfort with the device and was unable to explain its presence. Staff, including a nurse and the unit manager, were unaware of any incidents of attempted elopement by the resident and did not know why the wander guard was still in use. The Director of Nursing acknowledged that the resident should have been reassessed for elopement risk upon readmission and that a physician order should have been obtained for the wander guard's use.
Failure to Provide Ordered Speech Therapy Services
Penalty
Summary
The facility failed to provide speech therapy services as ordered for a resident who was reviewed for therapy services. The resident, who was admitted with a diagnosis of stroke with left side hemiplegia and dysarthria, was assessed at the hospital to be at moderate risk for aspiration and recommended for a puree diet with moderately thick liquids. A physician ordered a speech therapy evaluation and treatment, as well as a puree diet with honey thick liquids. However, the resident did not receive the speech therapy services as ordered. Interviews with the Rehabilitation Director revealed that although the normal process would include a speech therapy screen or evaluation for a newly admitted resident with such diagnoses, there was no documentation that the resident received a speech therapy screen or services. The facility was without a speech therapist for a period, and the Rehabilitation Director was on medical leave during that time. The Director of Nursing and the Nurse Practitioner were not aware that the resident did not receive speech therapy services. The Administrator acknowledged the absence of a speech therapist but did not recall the specific resident's case.
Failure to Post Nurse Staffing Information
Penalty
Summary
The facility failed to post nurse staffing information at the beginning of each shift for two out of four days during the survey and for 47 out of 57 days reviewed from May 1, 2024, through June 26, 2024. On June 26, 2024, it was observed that the nurse staffing information posted in the lobby was dated June 24, 2024. The Director of Nursing (DON) admitted that she and the Administrator were responsible for posting the information, but due to the new scheduler being in training, the posting for June 25, 2024, was completed but not displayed, and the posting for June 26, 2024, was forgotten. Further review revealed that there was no documentation of staff postings from May 1, 2024, to June 16, 2024. The DON explained that during May 2024, she was assisting another building and was unaware that the postings were not being completed. The Administrator confirmed that the scheduler at that time did not consistently complete the task, and the DON was attempting to keep them current. However, the staff postings were not completed in a timely manner.
Failure to Deliver Resident Mail on Saturdays
Penalty
Summary
The facility failed to ensure residents received their mail on Saturdays, impacting all 127 residents. Resident interviews revealed that mail was not consistently delivered on Saturdays unless the Activities Director or front office staff were present. The Business Office Manager confirmed that the receptionist was responsible for sorting mail, but resident mail was often left at the front desk until Monday unless it appeared to be a special item like a birthday card. The Administrator stated that the weekend receptionist was supposed to deliver mail on Saturdays, but this was not consistently happening.
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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