Nc State Veterans Home - Salisbury
Inspection history, citations, penalties and survey trends for this long-term care facility in Salisbury, North Carolina.
- Location
- 1601 Brenner Ave., Building #10, Salisbury, North Carolina 28145
- CMS Provider Number
- 345531
- Inspections on file
- 16
- Latest survey
- December 12, 2025
- Citations (last 12 mo.)
- 12 (1 serious)
Citation history
Health deficiencies cited at Nc State Veterans Home - Salisbury during CMS and state inspections, most recent first.
Staff failed to properly disinfect shared blood glucose meters before and after each use, using alcohol wipes instead of EPA-registered disinfectant wipes, and sometimes not disinfecting at all. This occurred during blood glucose checks for two residents with bloodborne pathogens, with staff demonstrating lack of knowledge about correct procedures despite prior training. The meters were not individually labeled or stored, leading to potential cross-contamination.
Two residents experienced a lack of dignity and respect for their rights when one was subjected to rough handling during bathing despite asking for it to stop, and another had their urine collection bag left uncovered and visible from the hallway after a medical procedure. Staff did not respond to resident requests or ensure privacy measures were maintained.
Two residents were administered antipsychotic and antidepressant medications without appropriate mental health diagnoses, and a PRN antipsychotic was ordered for longer than regulations allow. Staff, including the DON and Consultant Pharmacist, did not verify medication orders for compliance, relying instead on pharmacy review and assuming hospice orders were exempt from certain requirements.
A resident with dementia and chronic conditions reported being roughly handled by a nursing assistant during a shower, repeatedly asking for the care to stop. Despite the resident's complaints, neither the involved NA nor another NA who overheard the allegation reported it to administration or the charge nurse, allowing the accused NA to continue working. The incident was only reported days later by the resident's representative, resulting in delayed assessment and documentation, and a failure to follow the facility's abuse reporting policy.
A resident with chronic pain did not receive lidocaine patches as ordered by the physician, with nurses administering fewer patches than prescribed and failing to seek clarification or update the order. Both the DON and physician confirmed the order was not followed or clarified by staff.
A resident with an indwelling urinary catheter was observed on two occasions with their catheter collection bag lying on the floor, despite staff knowledge that the bag should be hung below the bladder and off the floor. Staff interviews confirmed awareness of proper catheter care, but the training materials did not specifically address bag placement. The deficiency was identified through direct observation and staff interviews.
Two residents received antipsychotic and antidepressant medications without appropriate diagnoses or correct PRN stop dates, and the Consultant Pharmacist failed to identify or report these drug regimen irregularities during monthly reviews. Facility staff were unaware of regulatory requirements for PRN antipsychotic duration and did not question physician orders, resulting in continued inappropriate medication use.
Nursing staff failed to accurately document and administer lidocaine patches as ordered for a resident with pain management needs. Nurses applied fewer patches than prescribed and signed the MAR as if the full dose was given, resulting in inaccurate medical records. The DON and ADON confirmed that the documentation did not reflect actual practice.
Two residents did not have proper documentation related to influenza vaccination: one did not have evidence of receiving vaccine education or a Vaccine Information Statement (VIS) prior to consenting, and another received the vaccine without a signed consent form, with only staff witness signatures indicating verbal consent. Facility staff acknowledged missing documentation and inconsistent practices, despite policy requirements for providing the VIS and documenting education and consent.
A resident with a history of tobacco use, stroke, and vascular dementia did not receive a required quarterly smoking safety screen, as mandated by facility policy. The resident, who required supervision while smoking, continued to participate in supervised smoking sessions. The DON confirmed that the assessment was not completed and that there was no system in place to ensure these evaluations were done on schedule.
The facility did not post a complete and current list of required state agency and advocacy group contact information, including the State Survey Agency, Adult Protective Services, Ombudsman Program, and others. Observations showed missing or outdated postings in key areas, and staff interviews revealed confusion about responsibility for maintaining these postings.
Two residents' representatives signed arbitration agreements without adequate explanation from facility staff. In one case, a representative was present with the Admissions Coordinator but was not given an explanation of the forms. In another, the representative received the paperwork electronically and had no verbal communication with staff, leading to confusion about the agreement's content.
Unlabeled items were found in nourishment rooms on both floors of the facility, including lactose-free milk, Gatorade, cherry coke, ice cream cones, and containers of ice cream. Dietary staff were unsure of ownership, and it was noted that nursing staff were responsible for labeling residents' items, while staff items were not allowed in these rooms.
A resident who was alert and independent expressed a preference to eat in the dining room during evening meals but was repeatedly denied this choice due to staff shortages. Staff interviews confirmed that residents were often unable to use the dining room for supper because staff were too busy assisting others. The DON and Administrator were unaware of the specific complaints, although the expectation was for residents to have dining choices.
A resident dependent on staff for personal hygiene due to a stroke and hemiplegia was not shaved as per their care plan. Despite the resident's preference for being shaved, staff did not fulfill this need due to time constraints and other priorities. Interviews with staff and administration confirmed the oversight in providing necessary personal hygiene care.
Failure to Properly Disinfect Shared Blood Glucose Meters
Penalty
Summary
Facility staff failed to properly clean and disinfect shared blood glucose meters before and after each use, as required by both facility policy and the manufacturer's instructions. Observations revealed that staff used alcohol wipes instead of EPA-registered disinfectant wipes, and in some cases, did not disinfect the meters at all prior to use. This practice was observed during blood glucose checks for two residents, both of whom were identified as having bloodborne pathogens, including hepatitis C. The blood glucose meters were not labeled for individual resident use and were stored in a manner that allowed for potential cross-contamination. Nursing staff, including a nurse and the Assistant Director of Nursing (ADON), demonstrated a lack of knowledge regarding the correct disinfection procedures. The nurse stated he was trained to use alcohol for cleaning, and the ADON admitted she was unaware that the meter needed to be cleaned both before and after each use. Both staff members had previously received training on blood glucose meter disinfection, but failed to follow the correct procedures during observed care. The facility's policy and the manufacturer's guidelines both specified the use of EPA-registered disinfectant wipes with a required contact time, which was not followed. The deficiency was identified during direct observation and interviews, which confirmed that the improper cleaning and disinfection of blood glucose meters occurred while caring for residents with known bloodborne pathogens. The facility's monitoring systems failed to detect or correct these lapses in infection control, and staff continued to use shared meters without proper disinfection, increasing the risk of cross-contamination and exposure to bloodborne infections among residents.
Removal Plan
- Removed and discarded prior blood glucose meters that were being utilized for multi-resident use.
- Placed individual blood glucose meters in a zipped plastic bag with resident's name identifier to prevent cross contamination.
- Blood glucose meters are removed from the zipped plastic bag prior to entering the resident room, then cleaned, disinfected, and air-dried per EPA-registered disinfectant wipe manufacturer's recommendation before and after use.
- Blood glucose meters are stored in each resident's respective medication cart.
- Applied residents' names to the individual blood glucose meters.
- Upon resident discharge, blood glucose meter is disinfected with EPA-registered disinfectant wipe and stored in medication room.
- All new admissions and residents with new blood glucose meter testing orders will be given a new blood glucose meter by the nurse receiving the order and/or admitting nurse.
- Nurse and/or admitting nurse will label the blood glucose meter and baggy with resident's name and place it in their respective medication cart.
- Education provided to all Licensed Nurses on the specific resident use of blood glucose meters, storage, cleaning, and disinfecting using proper EPA-disinfecting wipe.
- Licensed Nurses who have not received the education will be removed from the schedule until the education has been completed.
- Education related to cleaning, disinfecting, and storage of individual blood glucose meters will be added to the general orientation of newly hired Licensed Nurses.
- Administrator and/or Director of Health Services is responsible for ensuring all Licensed Nurses are educated.
- Licensed nurses who are scheduled to work will receive in-person education and complete return demonstration of cleaning and disinfecting blood glucose meters.
- Licensed Nurses who are not scheduled to work will receive over the phone education with return demonstration review by Director of Health Services prior to next scheduled shift.
- Administrator and/or Director of Health Services maintains the employee roster of those who have been educated and who require review.
- Facility contacted the local health department regarding the infection control breach.
- Medical Director was notified of the infection control breach.
Failure to Honor Resident Dignity and Rights
Penalty
Summary
The facility failed to honor a resident's right to dignity and self-determination in two separate incidents. In the first incident, a resident with chronic pain and dementia, who was moderately cognitively impaired and dependent on staff for bathing and toileting, requested that a nursing assistant stop a shower due to being handled roughly. Despite the resident's repeated requests to stop and expressions of discomfort, the nursing assistant continued with the shower and did not report the incident to supervisory staff. The resident later expressed fear of the nursing assistant and felt that his concerns were not being heard by staff. In the second incident, another resident with severe cognitive impairment and an indwelling catheter was observed multiple times with his urine collection bag visible from the hallway, lacking a privacy or dignity cover. The urine in the collection bag was visible to staff, visitors, and other residents passing by. Staff interviews confirmed that the privacy cover was not in place following the resident's return from a urology procedure, and that staff had not noticed or addressed the missing cover during their shifts. Both incidents demonstrate failures to maintain resident dignity and respect resident rights, as staff did not respond appropriately to resident requests or ensure privacy measures were in place. These deficiencies were identified through observations, record reviews, and interviews with residents, staff, and family members.
Failure to Ensure Proper Diagnosis and Regulatory Compliance for Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that two residents had appropriate diagnoses for the use of antipsychotic and antidepressant medications, and did not comply with regulations regarding the duration of PRN antipsychotic orders. For one resident with mild dementia, agitation, and brief psychotic disorder, a PRN order for Haldol was written for 60 days to manage agitation, without a proper diagnosis justifying its use for agitation and without adhering to the required 14-day stop date for PRN antipsychotics. The order was written by a Physician Assistant and hospice Physician, both of whom were unaware of the 14-day regulatory limit. The Consultant Pharmacist, who reviewed the order, did not question the extended duration or the diagnosis, assuming hospice orders were exempt, and the Director of Nursing stated that staff did not verify medication orders for accuracy or compliance with regulations. For another resident with unspecified dementia and no documented behavioral or psychotic disturbances, antipsychotic (olanzapine) and antidepressant (sertraline) medications were ordered and administered without a supporting mental health diagnosis. The resident's records and progress notes did not indicate behaviors or symptoms that would justify the use of these medications. The Physician Assistant and Assistant Director of Nursing confirmed that the medications were ordered for dementia without behaviors, and that no mental health diagnosis was present until after the deficiency was identified. The Director of Nursing acknowledged that the facility relied solely on pharmacy review for medication order accuracy and was unaware of the missing diagnoses until it was brought to their attention. These deficiencies were identified through record review and interviews with facility staff, the Consultant Pharmacist, and the prescribing clinicians. The facility's process lacked adequate checks to ensure that medication orders were supported by appropriate diagnoses and that regulatory requirements for PRN antipsychotic medications were followed.
Failure to Immediately Report and Protect Resident Following Allegation of Rough Handling
Penalty
Summary
The facility failed to follow and implement its abuse policy and procedures in the case of a resident with multiple diagnoses, including unspecified dementia, chronic obstructive pulmonary disease, and chronic pain. The resident reported that a nursing assistant (NA) was rough and manhandled him during a shower, and despite the resident's repeated requests for the NA to stop, the care continued. The resident expressed fear and distress, stating that staff did not listen when he tried to report the incident after returning to his room. Two nursing assistants were aware of the resident's allegations: one directly involved in the incident and another who overheard the resident's complaints. Neither assistant reported the incident to administration or the charge nurse as required by facility policy, allowing the NA in question to complete the shift and return to work the following day. The charge nurse on duty did not recall being informed of the incident, and the resident's representative did not immediately report the allegation to staff, only doing so during a subsequent visit after the resident repeated his account and appeared upset. The facility's policy required immediate reporting of any abuse allegations to the Administrator and safeguarding of the resident. However, the delay in reporting resulted in the accused NA continuing to work and potentially exposed other residents to risk. The initial assessment and documentation of the resident's condition were also delayed, with the skin and pain assessment not documented until days after the incident. Staff interviews revealed a lack of awareness or recall regarding the reporting of the incident, and the facility's investigation confirmed that the abuse allegation was not reported promptly as required by policy.
Failure to Administer Lidocaine Patches per Physician Order
Penalty
Summary
The facility failed to administer lidocaine 4% external pain patches according to the physician's order for one resident with diagnoses of right hip and low back pain. The physician's order specified that four lidocaine patches were to be applied daily to the resident's bilateral hips and bilateral lower back. However, review of the Medication Administration Record (MAR) and staff interviews revealed that nurses consistently failed to apply the prescribed number of patches. One nurse admitted to applying only two patches on the dates she worked, choosing either the hips or the lower back, and stated she did not seek clarification or a new order from the physician despite her belief that the resident no longer needed four patches. Another nurse reported only applying one patch on the dates she worked, acknowledging awareness of the order but unable to explain why she did not follow it, nor did she request clarification from the physician. The physician confirmed that the order was for four patches daily and stated that no staff had contacted him for clarification or to change the order. The Director of Nursing and Assistant Director of Nursing also confirmed that the nurses should have either followed the physician's order or sought clarification if there were questions. The failure to administer the medication as ordered was identified through observations, record reviews, and staff and physician interviews.
Catheter Collection Bag Found on Floor
Penalty
Summary
A deficiency was identified when a resident with severe cognitive impairment and an indwelling urinary catheter was observed on two separate occasions with their urinary catheter collection bag lying on the floor, both in the dining area and in bed. The bag was covered for privacy, but its placement on the floor was directly observed by surveyors. Staff interviews revealed that nursing assistants and nurses were aware that catheter bags should not be on the floor and should be hung below the bladder, but none reported seeing the bag on the floor during their shifts. The Assistant Director of Nursing and the Physician Assistant both confirmed that it was unacceptable for the catheter bag to be on the floor due to the increased risk of infection. Record review indicated that the resident's care plan included a goal to prevent complications or injury related to catheter use. Training records showed that staff had received education on catheter care, but the provided training materials did not specifically address the proper placement of the catheter collection bag. Despite staff knowledge and training, the deficiency occurred due to the failure to ensure the catheter bag was consistently kept off the floor, as required for infection prevention.
Failure to Identify and Report Drug Regimen Irregularities During Monthly Pharmacist Reviews
Penalty
Summary
A deficiency occurred when the Consultant Pharmacist failed to identify and report drug regimen irregularities for two residents during monthly medication reviews. For one resident with mild dementia, brief psychotic disorder, and anxiety, a PRN order for Haldol (haloperidol) was written for 60 days for agitation, with the diagnosis listed as dementia with agitation. The Consultant Pharmacist did not document any recommendations or irregularities regarding the inappropriate duration of the PRN antipsychotic order, which should have been limited to 14 days, nor did she question the diagnosis or the order, assuming it was acceptable due to the resident's hospice status. Interviews with facility staff revealed a lack of awareness about the 14-day limit for PRN antipsychotic medications and a reluctance to question hospice physician orders, even when the diagnosis or duration was incorrect. For another resident with unspecified dementia without behavioral or psychotic disturbances, physician orders were in place for olanzapine (an antipsychotic) and sertraline (an antidepressant), both prescribed for dementia without behaviors. The Consultant Pharmacist's monthly reviews did not document any recommendations or irregularities regarding the lack of appropriate diagnoses for these medications. Although the Pharmacist stated that a message was sent to the physician to review the diagnosis for sertraline, there was no documentation of this notification, and the issue with olanzapine was not addressed in a timely manner. The Physician Assistant confirmed that there were no current diagnoses of depression or psychosis for this resident, and the Assistant Director of Nursing acknowledged that the medications were prescribed without a mental health diagnosis. Throughout the review period, the Consultant Pharmacist did not consistently identify or report medication irregularities related to the indicated use and scheduled stop dates of antipsychotic and antidepressant medications for the two residents. Facility staff, including the DON and ADON, confirmed that medication orders were only checked monthly by the Consultant Pharmacist and that no recommendations or notifications regarding these irregularities were received. This lack of identification and reporting of drug regimen irregularities resulted in the continuation of inappropriate medication orders for both residents.
Inaccurate Documentation of Medication Administration
Penalty
Summary
The facility failed to maintain accurate medical records and ensure proper documentation of medication administration for a resident with orders for lidocaine adhesive patches. The resident had a physician's order specifying the application of four 4% lidocaine patches daily to bilateral hips and lower back. However, observations and interviews revealed that nursing staff did not follow the order as written. One nurse consistently applied only two patches, either to the resident's low back or hips, and documented in the Medication Administration Record (MAR) as if all four patches were administered. Another nurse admitted to applying only one patch per administration, despite signing the MAR for four patches, and could not provide a reason for not following the order. Both nurses acknowledged that their documentation on the MAR was inaccurate, as it did not reflect the actual number of patches applied. The Director of Nursing and Assistant Director of Nursing confirmed that the nurses should have clarified the order if they were not administering the medication as prescribed, and agreed that the documentation was not accurate. The deficiency was identified through observations, record reviews, and staff interviews, which demonstrated a pattern of inaccurate documentation and failure to follow physician orders for medication administration.
Failure to Document Vaccine Education and Obtain Proper Consent for Influenza Vaccination
Penalty
Summary
The facility failed to properly document education regarding the influenza vaccine for one resident and failed to obtain a required signature on the influenza vaccine consent/refusal form for another resident. In the first instance, a resident who was cognitively intact consented to receive the influenza vaccine and signed the consent form, but there was no Vaccine Information Statement (VIS) attached, nor was there documentation in the electronic medical record (EMR) indicating that education about the vaccine was provided to the resident or their representative. The Infection Preventionist confirmed that she did not always bring a VIS form when discussing vaccination and that documentation of education was missing from the EMR. Both the Director of Nursing (DON) and the Administrator were unable to explain why the VIS was not provided or why education was not documented, despite facility policy requiring that the VIS be provided and education documented prior to vaccine administration. In the second case, another resident with moderate cognitive impairment had a consent form marked as consenting to the influenza vaccine, but neither the resident nor their representative had signed the form. The form was witnessed by two staff members, including the Infection Preventionist, who stated that she witnessed verbal consent but did not document this on the form. The vaccine was administered without a resident or representative signature, and the VIS form attached also lacked the required signature. The DON stated that the resident likely refused to sign but gave verbal consent, yet there was no documentation of verbal or telephone consent as required. Interviews with staff revealed inconsistent practices regarding the provision and documentation of vaccine education and consent. The Infection Preventionist, DON, and Administrator all acknowledged gaps in documentation and were unable to provide reasons for the missing information. Facility policy required that the VIS be provided and education documented prior to vaccine administration, but these steps were not consistently followed or recorded for the residents involved.
Failure to Complete Required Smoking Safety Screen for Resident
Penalty
Summary
The facility failed to complete a required quarterly smoking safety screen for a resident with a history of tobacco use, cerebral vascular accident, and vascular dementia. According to the facility's policy, staff are required to evaluate each resident's ability to safely use smoking materials and determine the level of supervision needed. The resident's previous assessment indicated the need for supervision while smoking, as the resident was unable to hold or extinguish cigarettes independently. However, the August 2025 Nursing Quarterly Assessment did not include the mandated smoking safety screen for this resident. Interviews with the resident confirmed ongoing participation in supervised smoking during designated times. The DON acknowledged that quarterly smoking safety screens are required and that staff nurses are responsible for completing these assessments. Upon review, the DON was unable to provide documentation of the August 2025 assessment and confirmed there was no system in place to ensure timely completion of these required evaluations.
Failure to Post Required State Agency and Advocacy Group Contact Information
Penalty
Summary
The facility failed to post a complete and up-to-date list of names, addresses (including mailing and email), and telephone numbers of all required state agencies and advocacy groups, such as the State Survey Agency, Adult Protective Services, State Long-Term Care Ombudsman Program, Resident Advocacy Network, Home and Community Based Service Programs, and the Medicaid Fraud Control Unit. Observations conducted over four days revealed that the front hallway bulletin board lacked this required signage. While Resident Rights posters with the local Ombudsman's contact information were present at the first-floor nurses station and the second-floor nurses station, the latter displayed outdated information. No other postings for the required agencies or advocacy groups were observed in the facility. Interviews with facility staff, including the Recreation Director, Social Worker, and Administrator, confirmed that the responsibility for maintaining these postings was unclear and that the required information had not been posted for over three years. The Recreation Director updated the Ombudsman's contact information when notified of changes but was not involved with other postings. The Social Worker was unaware of the status of the postings, and the Administrator believed the postings were current but later acknowledged the required information had not been posted during his tenure.
Failure to Explain Arbitration Agreement to Resident Representatives
Penalty
Summary
The facility failed to adequately inform resident representatives about the arbitration agreement prior to obtaining their signatures. For two residents reviewed, the representatives either did not have the agreement explained to them or were not given the opportunity for verbal communication regarding the content of the agreement. In one case, the representative sat with the Admissions Coordinator during the pre-admission meeting, but reported that the Coordinator did not explain any of the forms and only indicated where to sign. The arbitration agreement for this resident was signed without either the acceptance or declination box being checked. In another instance, the representative received the admission paperwork, including the arbitration agreement, via email and was instructed to sign without any verbal explanation or communication from the Admissions Coordinator. The representative had to interpret the paperwork independently and later expressed a lack of understanding about the agreement. Interviews with facility staff confirmed that forms were sent electronically with an offer to answer questions if contacted, but no proactive explanation was provided. The DON acknowledged that forms should be explained if not understood, but this was not done in these cases.
Unlabeled Items Found in Nourishment Rooms
Penalty
Summary
The facility failed to remove unlabeled items from nourishment rooms on both the first and second floors, as observed during a survey. On the second floor, a bottle of lactose-free milk, a bottle of orange Gatorade, and an opened bottle of cherry coke were found in the refrigerator without labels. Dietary staff were unsure if these items belonged to residents or nursing staff, but acknowledged that they should not have been in the refrigerator unlabeled. It was noted that nursing staff were responsible for labeling items belonging to residents, and staff items were not permitted in the nourishment rooms. On the first floor, two push-up ice cream cones and two open containers of ice cream were also found unlabeled. Dietary staff and a nurse indicated that these items belonged to a resident, but they could not recall which resident. The Director of Nursing and the Administrator confirmed that nursing staff had been educated to label residents' items and that dietary staff were expected to check nourishment rooms daily for unlabeled items. However, the Dietary Manager was unavailable for an interview during the survey.
Failure to Honor Resident Dining Preferences
Penalty
Summary
The facility failed to honor a resident's preference for dining in the dining room during evening meals. The resident, who was alert, oriented, and independent but required setup for eating, expressed a desire to eat in the dining room with friends. However, the resident was repeatedly told by staff that dining in the dining room was not possible due to staff shortages, particularly on weekends and sometimes during the week. Interviews with staff members confirmed that residents were often unable to use the dining room for supper because staff were too busy assisting residents who required help, leaving no time to accommodate those who wanted to dine in the dining room. The Director of Nursing acknowledged that there were instances when dining in the dining room was not allowed and stated that staff had been educated to permit residents to choose their dining preferences. However, the Director of Nursing and the Administrator were not aware of the specific complaints from the resident about being unable to eat in the dining room. The Administrator expected residents to have a choice in dining but was unaware that nursing staff were not following this expectation.
Failure to Provide Personal Hygiene Care
Penalty
Summary
The facility failed to provide adequate personal hygiene care for a resident who was dependent on staff assistance due to a stroke and hemiplegia. The resident was admitted with these conditions and required moderate assistance with personal hygiene, including shaving. Despite the care plan indicating the need for staff assistance with personal hygiene, the resident was observed with a full beard, approximately 1/2 inch long, and expressed a preference for being shaved, which was not fulfilled by the staff. The deficiency was further highlighted during interviews with staff members. Nurse Aide #2 admitted to not shaving the resident during a shower session due to time constraints and other residents needing showers. The Assistant Director of Nursing confirmed that shaving should be provided during shower times, and the Administrator acknowledged that while the resident sometimes refused shaving, staff should ensure it is done. This indicates a lapse in following the care plan and ensuring the resident's personal hygiene needs were met.
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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