Peak Resources - Brookshire, Inc
Inspection history, citations, penalties and survey trends for this long-term care facility in Hillsborough, North Carolina.
- Location
- 300 Meadowlands Drive, Hillsborough, North Carolina 27278
- CMS Provider Number
- 345439
- Inspections on file
- 23
- Latest survey
- April 16, 2026
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Peak Resources - Brookshire, Inc during CMS and state inspections, most recent first.
The facility failed to send the Ombudsman copies of required Notices of Transfer/Discharge for three residents who were discharged to an assisted living facility, discharged home, or transferred to a hospital for acute care. Instead of forwarding the actual notices on the date they were issued, staff emailed periodic Admit/Discharge Reports that only listed resident names, discharge dates, and destinations. The Social Worker, DON, and Administrator all reported they believed these summary reports met the requirement, despite prior education from the Ombudsman that copies of all transfer/discharge notices for all discharges and emergency transfers must be provided.
A facility failed to notify a physician when a dental service consultation for a tooth extraction could not be scheduled for a resident with a history of dental issues. The resident required hospital-based treatment due to health concerns, but the Unit Manager delayed sending a referral and did not follow up. The resident experienced tooth pain, and the physician was not informed of the scheduling issue, preventing timely alternative arrangements.
A facility failed to provide timely written notification to a resident and their responsible party regarding the reason for the resident's transfer to the hospital. The resident, who was cognitively intact and had a diagnosis of Type 2 diabetes mellitus with a foot ulcer, was aware of the need to be transferred to the emergency room for evaluation. However, there was no evidence in the records that a discharge or transfer notice was sent to the resident or their responsible party. The Business Office Manager acknowledged missing the notification process, which was discovered during an audit.
A facility failed to provide a resident with written notification of the bed hold policy upon transfer to the hospital. The resident, who had Type 2 diabetes with a foot ulcer, was transferred to the emergency room but did not receive the bed hold policy. Staff interviews revealed lapses in procedure, with the Business Office Manager failing to follow up due to being off-duty. Consequently, the resident was discharged to another facility when no beds were available upon hospital discharge.
A facility failed to allow a resident to return after hospitalization due to a lack of available beds, violating the bed-hold policy. The resident, who was cognitively intact and had diabetes with a foot ulcer, was discharged to another facility. The Admissions Coordinator did not communicate the bed-hold policy or offer a bed when one became available. The Administrator was unaware of the requirement to allow residents to return to the first available bed.
The facility failed to develop individualized care plans for three residents, neglecting areas such as pain management, anticoagulant and diuretic use, and behavioral needs. A resident with pain did not have a care plan despite being on pain medication. Another resident on anticoagulants and diuretics lacked a care plan focus for these medications. Additionally, a cognitively impaired resident using markers inappropriately did not have a care plan addressing the need for non-toxic markers and staff redirection.
A resident with multiple health conditions required a tooth extraction, but the facility failed to obtain the necessary dental services. Despite being referred to an oral surgeon, the procedure could not be performed in an outpatient setting due to the resident's need for IV sedation. The facility delayed sending a referral to a dental school and did not follow up, resulting in the resident not receiving the required dental care.
The facility failed to implement infection control policies when a nurse aide and a housekeeper did not wear the required PPE before entering rooms with residents on special contact-droplet precautions. The nurse aide entered a resident's room with only a surgical mask, and the housekeeper was observed mopping with insufficient PPE, despite signage indicating the need for full protective gear. Both staff members were unaware of the requirements, and the Director of Nursing noted that staff were not reading the signs.
Failure to Send Required Transfer/Discharge Notices to Ombudsman
Penalty
Summary
The deficiency involves the facility’s failure to provide the Ombudsman with copies of the required Notices of Transfer/Discharge for three residents who were discharged or transferred. For one resident, admitted on an unspecified date, the Discharge/Transfer Plan of Care form showed a discharge to an assisted living facility on 1/14/26 after health needs had been met. Progress notes and the facility’s Admit/Discharge Report for 1/1/26–1/31/26 confirmed this discharge to another health care institution. The Social Worker reported that she emailed the Ombudsman the Admit/Discharge Report on 2/3/26, which listed the resident’s discharge, but she did not send the actual Notice of Transfer/Discharge and stated she was unaware this was required. The Ombudsman confirmed she did not receive the notice and stated she had previously educated the Social Worker and Administrator that copies of all Notices of Transfer/Discharge for all discharges and emergency transfers must be sent on the date the notice is issued. A second resident, also admitted on an unspecified date, was discharged home on 12/17/25, as documented in a progress note and the Admit/Discharge Report for 12/1/25–12/31/25. The Social Worker stated that on 1/8/26 she emailed the Ombudsman the Admit/Discharge Report for that period, which showed the resident’s discharge home, but again did not send a copy of the Notice of Transfer/Discharge and reported she did not know this was required. The Ombudsman confirmed she did not receive the notice for this discharge and reiterated that she had educated the Social Worker and Administrator that the Ombudsman must receive a copy of all Notices of Transfer/Discharge for all discharges and emergency transfers on the date the notice is issued. The Administrator acknowledged receiving education from the Ombudsman but stated he believed that sending the Admit/Discharge Report fulfilled the requirement. The third resident, admitted on an unspecified date, was transferred to the hospital on 1/22/26 for evaluation and treatment of an acute abdominal condition that could not be treated in the facility, following a request from the resident’s representative and an order from the provider. The Admit/Discharge Report for 1/1/26–1/31/26 showed this transfer as a discharge with expected return for inpatient care. The Social Worker stated she emailed the Ombudsman the Admit/Discharge Report on 2/3/26, which included the resident’s name and hospital admission location, but she did not send the Notice of Transfer/Discharge and believed only basic discharge information (name, date, location) was required. The Ombudsman confirmed she did not receive the notice for this hospital transfer and stated she had previously instructed the facility to send copies of all Notices of Transfer/Discharge for all discharges and emergency transfers on the date issued. The DON and Administrator both reported they were unaware that the actual transfer documents, rather than summary report data, were required to be sent to the Ombudsman.
Failure to Notify Physician of Dental Service Scheduling Issue
Penalty
Summary
The facility failed to notify the physician when a dental service consultation for a tooth extraction could not be scheduled for a resident. The resident, who was cognitively intact, had a history of dental issues including exfoliation of teeth due to systemic causes and a periapical abscess. A consultation on 12/5/24 revealed that the resident was not a candidate for treatment in an office setting due to her health history and required the procedure to be done in a hospital setting. The Unit Manager received this consultation report and faxed it to the contracted mobile dentist but did not follow up promptly. The Unit Manager delayed sending a referral to a dental school until 1/22/25 and did not follow up to confirm if the resident could be seen for the procedure. The resident expressed having tooth pain, and the contracted mobile dentist noted sensitivity and pain during an exam. The physician was not informed of the difficulty in scheduling the procedure, which could have allowed her to seek alternatives. The physician noted the importance of addressing the resident's dental needs outside of an emergency setting, highlighting the facility's failure to communicate effectively and ensure timely care for the resident's dental condition.
Failure to Notify Resident and Responsible Party of Hospital Transfer
Penalty
Summary
The facility failed to provide timely written notification to a resident and their responsible party regarding the reason for the resident's transfer to the hospital. The resident, who was cognitively intact and had a diagnosis of Type 2 diabetes mellitus with a foot ulcer, was aware of the need to be transferred to the emergency room for evaluation. However, there was no evidence in the records that a discharge or transfer notice was sent to the resident or their responsible party. The resident was discharged to the hospital for an acute condition and did not return to the facility. Interviews with facility staff revealed that the Business Office Manager (BOM) was responsible for issuing the discharge/transfer notice but failed to do so in this instance. The BOM acknowledged missing the notification process, which was discovered during an audit conducted by the Regional Business Office Manager. The facility's administrator confirmed that the notice of transfer should have been provided to the resident and/or their responsible party.
Failure to Provide Bed Hold Policy Notification
Penalty
Summary
The facility failed to provide written notification of the bed hold policy when a resident was transferred to the hospital. This deficiency was identified for a resident who was admitted with a diagnosis of Type 2 diabetes mellitus with a foot ulcer. The resident was cognitively intact and was aware of the need to be transferred to the emergency room for evaluation. However, there was no evidence that the bed hold policy was sent with the resident when he was unexpectedly discharged to the hospital. Consequently, when the resident was ready to discharge from the hospital, he was informed that there were no beds available at the facility, and he was discharged to another rehabilitation facility. Interviews with facility staff revealed that the Director of Nursing stated that nurses usually print copies of the bed hold policy to send with the hospital transfer form, but this was not documented. Nurse #3 mentioned that the bed hold policy was usually sent but sometimes they ran out of copies. The Business Office Manager admitted that the bed hold policy was not sent to the resident or his responsible party, as she was off the day the resident was sent to the hospital and failed to follow up. The Administrator was unaware of the requirement to allow a discharged resident to return to the first available bed when none were available at the time of their discharge from the hospital.
Failure to Allow Resident Return Post-Hospitalization
Penalty
Summary
The facility failed to allow a resident to return after hospitalization, violating the bed-hold policy. Resident #70, who was cognitively intact and had diagnoses including type 2 diabetes mellitus with a foot ulcer and cellulitis, was transferred to the hospital for an acute condition. Upon discharge from the hospital, the resident was informed that there were no available beds at the facility and was subsequently discharged to another rehabilitation facility. The facility's failure to provide the bed-hold policy to the resident or his responsible party contributed to this issue. Interviews with the Admissions Coordinator revealed that she did not communicate the bed-hold policy to the resident or his responsible party and did not offer a bed when one became available. The facility census on the day of the resident's discharge showed only one semiprivate female bed was available, and the Admissions Coordinator admitted to not offering it to the resident. The Administrator was unaware of the requirement to allow residents to return to the first available bed when no beds were available at the time of hospital discharge. Attempts to contact the hospital case manager for further clarification were unsuccessful.
Failure to Develop Individualized Care Plans for Residents
Penalty
Summary
The facility failed to develop individualized person-centered care plans for three residents in key areas such as pain management, anticoagulant and diuretic use, and behaviors. Resident #32, who was admitted with a diagnosis that included pain, did not have a care plan for pain management despite being prescribed Oxycodone and Gabapentin. The MDS Coordinator acknowledged the oversight in not developing a comprehensive care plan for Resident #32's pain management. Similarly, Resident #21, who was admitted with atrial fibrillation and essential hypertension, was prescribed Eliquis and furosemide, but their care plan lacked a focus on anticoagulant and diuretic use. The MDS Nurse confirmed that these elements should have been included in the care plan. Resident #63, who was cognitively impaired and had a history of using markers inappropriately, did not have a care plan that addressed the need for only non-toxic markers and staff redirection. Despite observations and staff awareness of the behavior, the care plan was not updated to reflect these needs. Interviews with the Activities Director, Unit Manager, and Medical Director revealed that while non-toxic markers were provided, there was concern for Resident #63's safety, and the care plan should have been revised to address the behavior. The DON confirmed that the change in behavior was discussed in meetings, but the care plan was not updated accordingly.
Failure to Obtain Recommended Dental Services for Resident
Penalty
Summary
The facility failed to obtain recommended dental services for a resident, identified as Resident #32, who was admitted with multiple health conditions including exfoliation of teeth due to systemic causes, hypertensive heart disease, chronic kidney disease, and a periapical abscess. Despite being cognitively intact and not exhibiting significant pain or weight changes, Resident #32 required a tooth extraction due to sensitivity and possible nerve damage. The contracted mobile dentist initially examined her and referred her to an oral surgeon for the procedure, which could not be performed in an outpatient setting due to her need for IV sedation and her medical conditions. The oral surgeon recommended that the procedure be done in a hospital setting, but the facility did not follow up promptly. The Unit Manager delayed sending a referral to a dental school until over a month after the oral surgeon's consultation and did not follow up to confirm if the procedure could be completed. The Social Worker, responsible for completing referrals, was unaware of the oral surgeon's recommendations and had not been informed to assist in finding a hospital for the procedure. Consequently, Resident #32 had not been seen by a dentist for an oral exam since the oral surgeon's consultation. Interviews with the Director of Nursing and the resident's physician revealed that the facility had not effectively coordinated the necessary dental care. The physician noted the difficulty in finding a dentist to perform the procedure under general anesthesia due to the resident's health conditions. The facility's lack of timely follow-up and coordination resulted in the resident not receiving the required dental extraction, despite the resident being clinically stable and not exhibiting significant pain.
Failure to Implement Infection Control Policies
Penalty
Summary
The facility failed to implement its infection control policies and procedures when two staff members, Nurse Aide #1 and Housekeeper #1, did not don the required Personal Protective Equipment (PPE) before entering rooms with residents on special contact-droplet precautions. Nurse Aide #1 entered a resident's room wearing only a surgical mask to deliver a lunch meal tray, despite the signage indicating the need for full PPE due to the resident being on isolation precautions for Respiratory Syncytial Virus (RSV) and Influenza. Nurse Aide #1 expressed confusion, believing that full PPE was not necessary if not providing direct patient care. Similarly, Housekeeper #1 was observed mopping the floor in another resident's room while wearing only a surgical mask and gloves, contrary to the special droplet contact precautions signage that required a gown, N95 respirator, and face shield. Housekeeper #1 was unaware of the PPE requirements, and the Director of Nursing acknowledged that staff were not reading the signs, attributing this to the facility not having had an isolation case in a while. The Administrator also indicated that staff should read the signs to understand the necessary precautions before entering a room.
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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