Peak Resources - Alamance, Inc
Inspection history, citations, penalties and survey trends for this long-term care facility in Graham, North Carolina.
- Location
- 215 College Street, Graham, North Carolina 27253
- CMS Provider Number
- 345337
- Inspections on file
- 22
- Latest survey
- March 5, 2026
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Peak Resources - Alamance, Inc during CMS and state inspections, most recent first.
Surveyors found multiple medication storage and labeling deficiencies in two medication storerooms, including expired Allegra D and nicotine patches left on a shelf, and a glucagon pen for a resident stored in a refrigerator contrary to manufacturer instructions requiring room temperature storage. In another storeroom, an opened multi-dose vial of Tuberculin PPD was kept in a refrigerator without any notation of the date it was opened, despite manufacturer directions that it be discarded 30 days after opening. The unit manager and DON acknowledged that nursing staff and supervisors share responsibility for ensuring medications are in date, properly stored, and labeled when opened.
Surveyors found that MDS assessments were inaccurately coded for two residents. One resident with an underactive bladder had an indwelling urinary catheter discontinued and was receiving intermittent catheterizations, yet subsequent quarterly MDS assessments continued to code an indwelling catheter. Another resident receiving an antipsychotic, antidepressant, and diuretic, with no opioid orders or administration, was coded on the MDS as receiving an opioid and had no documented indications for use recorded for any of the medications. The MDS nurse acknowledged these coding errors and omissions during interviews.
A resident with a right foot fracture, cerebral palsy, and muscle weakness, who required assistance with several ADLs and was receiving PT/OT, had a documented goal to return home with home health services. Although orders and therapy discharge summaries specified discharge home with home health PT, OT, and case management, the care plan and progress notes lacked discharge planning details, and the discharge plan stated that home health would be arranged prior to discharge. The resident was discharged home and later reported that she had been told home health would be set up before leaving but did not hear from the agency until several days afterward, relying on friends for help. Interview and documentation from the home health agency and a fax confirmation showed that the facility did not send the referral until the day after discharge, resulting in a delay in initiation of home health services.
A resident with cognitive and developmental disabilities fell from a mechanical lift due to improper use by two nurse aides. The resident was lifted into the air, but one aide let go of the hand holds, causing the resident to slide out and fall. The resident was assessed for injuries and diagnosed with a scalp hematoma. The facility conducted a root cause analysis and provided reeducation on proper lift techniques.
The facility's QAPI committee failed to maintain procedures and monitor interventions, resulting in a repeat deficiency in supervision to prevent accidents. During a complaint investigation, the facility failed to prevent a fall from a mechanical lift and provide safe incontinent care for residents.
Expired, Improperly Stored, and Undated Medications in Medication Storerooms
Penalty
Summary
Surveyors identified deficiencies in the facility’s handling and storage of medications in two medication storerooms. In the Station 1 Medication Storeroom, an observation revealed an unopened box of Allegra D with a manufacturer’s expiration date of November 2025 that was expired, and an opened box of 14 mg nicotine transdermal patches with a manufacturer’s expiration date of January 2026 that was also expired. Additionally, an unopened 1 mg glucagon pen dispensed for Resident #43 was found stored in the medication storeroom refrigerator at 40°F, despite the manufacturer’s label directing storage at controlled room temperature between 68°F and 77°F. The Station 1 Unit Manager acknowledged responsibility for checking the storeroom to ensure medications were not expired and were stored properly. The DON later stated that everyone, including supervisors, was responsible for checking the medication storeroom and confirmed that glucagon should not be stored in the refrigerator. In the Station 3 Medication Storeroom, surveyors observed an opened multi-dose vial of Tuberculin PPD injectable solution in the medication storeroom refrigerator. The vial and its manufacturer’s box, dispensed from the pharmacy on January 28, 2026, were not labeled with the date the vial was opened, preventing determination of the shortened expiration date. Manufacturer instructions for the multi-dose PPD vial indicated it should be discarded 30 days after opening. Nurse #1 stated the vial would need to be discarded. During an interview, the DON reiterated that everyone, including supervisors, was responsible for checking the medication storeroom to ensure medications were properly stored and within date, and stated that she expected the nurse who opened a medication to date the label with the opening date.
Inaccurate MDS Coding for Catheter Use and Medication Regimen
Penalty
Summary
The deficiency involves inaccurate coding of MDS assessments for two residents, resulting in failure to ensure accurate resident assessments. For one resident with a diagnosis including flaccid neuropathic (underactive) bladder, physician orders initially directed use of an indwelling urinary catheter with catheter care every shift, and later discontinued the indwelling catheter in favor of intermittent catheterization as needed. Nursing documentation on the MAR showed catheter care every shift from early July through mid-August, consistent with the indwelling catheter order until it was discontinued. However, the quarterly MDS assessments completed after the resident had transitioned to intermittent catheterization continued to code the resident as having an indwelling urinary catheter. The MDS coordinator who completed these assessments acknowledged during interview that the resident no longer had an indwelling catheter at the time of the assessments and that the MDS should have been coded to reflect intermittent catheter use instead. For another resident admitted with mood disorder, major depressive disorder, pain, and later localized edema, physician orders and the MAR showed daily administration of Risperdal for mood disorder, Duloxetine for major depressive disorder, and Furosemide/Lasix for localized edema, with no orders or administration of opioid medications. A quarterly MDS assessment for this resident, completed by the same MDS nurse, coded the resident as receiving medications from the antipsychotic, antidepressant, diuretic, and opioid drug classes, and did not document indications for use for any of these medications. During interview, the MDS nurse stated that omitting the indications for use was an oversight, confirmed that the resident had diagnoses supporting the use of antipsychotic, antidepressant, and diuretic medications, and acknowledged that the resident did not receive any opioid medications and that coding opioid use was a mistake.
Failure to Arrange Timely Home Health Referral Prior to Discharge
Penalty
Summary
The deficiency involves the facility’s failure to implement an effective discharge planning process to ensure timely referral for home health services prior to a resident’s discharge home. The resident had diagnoses including a displaced fracture of the right second metatarsal, cerebral palsy, and muscle weakness, and required assistance or supervision with several ADLs. The 5‑day MDS documented that the resident was cognitively intact, receiving PT and OT, and had an overall discharge goal of returning to the community with active discharge planning noted. However, the resident’s care plan dated 01/10/2025 contained no information related to discharge planning, and progress notes from 01/07/2025 through 01/31/2025 contained no documentation of discharge planning activities. Therapy documentation showed that the resident exhausted therapy benefits on 01/25/2025 and would require home health OT and PT upon discharge. An order dated 01/28/2025 directed discharge home with home health PT, OT, and case management services. The OT and PT discharge summaries indicated that the interdisciplinary team was to coordinate a discharge that included home health services. A nurse practitioner documented a face‑to‑face encounter on 01/30/2025, certified the resident as homebound, ordered home health PT and OT, and indicated that required home health documentation was reviewed and communication with the home health agency occurred. Despite these orders and certifications, there was no evidence in the record that a referral to home health was actually sent before the resident left the facility. The resident was discharged home on 01/31/2025, with the discharge/transfer plan of care stating that she was to be set up with home health PT, OT, and case management prior to discharge and that she left by car with a friend. The resident later reported that the social worker had told her home health services would be arranged before she went home, but she did not hear from home health until several days after discharge and relied on friends for help in the interim. Home health records and interview confirmed that the referral paperwork, which included a home health order dated 01/28/2025, was first received by the home health agency on 02/01/2025, after the resident had already been discharged. A fax confirmation from the facility also showed the referral was sent on 02/01/2025, and there was no evidence of any earlier referral, demonstrating that the facility did not complete the home health referral prior to discharge as planned.
Failure to Prevent Fall from Mechanical Lift
Penalty
Summary
The facility failed to prevent a fall from a mechanical lift for a resident with multiple diagnoses, including a cognitive and developmental disability and spinal stenosis. The incident occurred when two nurse aides were transferring the resident using a mechanical lift. The resident was placed on a lift pad and lifted into the air, but one of the nurse aides let go of the hand holds on the lift pad, causing the resident to slide out of the top of the lift pad and fall to the floor. The resident was assessed for injuries and sent to the emergency room, where a scalp hematoma was diagnosed, but no major trauma or pain was noted. The nurse aides involved in the incident confirmed that they had used the same-colored straps on the hooks of the mechanical lift and crossed the straps between the resident's legs to keep her secure. However, one of the nurse aides removed her hands from the hand holds on the lift pad to move the wheelchair into position, which led to the resident sliding out of the lift pad. The Director of Nursing (DON) conducted a root cause analysis and determined that the lift pad was positioned incorrectly during the transfer, and a nurse aide let go of the hand holds while the resident was in the air. The DON and the nursing staff recreated the incident to identify the errors and provided reeducation on the proper use of the mechanical lift. The staff were trained on how to access the resident profile for choosing the correct lift pad, ensuring wheelchairs are in position before starting the transfer, and always keeping hold of the hand holds while the resident is in the air. The facility also conducted competency checks and audits to ensure proper mechanical lift techniques were being followed by the nursing staff.
Repeat Deficiency in Supervision to Prevent Accidents
Penalty
Summary
The facility's Quality Assessment Performance Improvement (QAPI) committee failed to maintain implemented procedures and monitor interventions following a complaint investigation completed on 9/19/2023. This resulted in a repeat deficiency in the area of supervision to prevent accidents. Specifically, during a complaint investigation on 4/24/2024, the facility failed to prevent a fall from a mechanical lift for one of three residents reviewed for supervision to prevent accidents. Additionally, during the complaint investigation on 9/19/2023, the facility failed to provide safe incontinent care for one of three residents reviewed for accidents. The Administrator confirmed that the QAPI committee, which includes various department heads, was not effectively sustaining the QAPI process, as evidenced by the repeated deficiencies and non-compliance identified by the corporate office after the fall incident involving a resident and a mechanical lift.
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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