Peak Resources- Shelby
Inspection history, citations, penalties and survey trends for this long-term care facility in Grover, North Carolina.
- Location
- 726 South Battleground Ave, Grover, North Carolina 28073
- CMS Provider Number
- 345229
- Inspections on file
- 25
- Latest survey
- February 11, 2026
- Citations (last 12 mo.)
- 7
Citation history
Health deficiencies cited at Peak Resources- Shelby during CMS and state inspections, most recent first.
A resident with type 2 DM had a new weekly semaglutide order entered into the EMR, but the drug was not available on multiple scheduled administration dates and was not actually given. An RN documented on the MAR that the dose was administered on one date and refused on another, later acknowledging these entries were incorrect and that the medication had been unavailable. There was no documentation that the MD/PA was notified that the ordered semaglutide was not being administered, and the PA reported she was unaware the medication had not been delivered or given until weeks later. The Administrator confirmed that providers are to be notified whenever a resident does not receive a prescribed medication, regardless of unavailability or refusal.
A resident with type 2 DM, weight gain, and varying blood sugars was started on weekly semaglutide by a PA after consultation with the medical director, but the order sent to the pharmacy lacked a specific dose. The pharmacist repeatedly notified the former DON that the order required clarification before the drug could be dispensed, yet no corrected order with dosage was provided until a new order specifying 0.25 mg was entered weeks later. During this period, nursing staff documented the drug as given or refused on the MAR despite it being unavailable on multiple dates, and the unit manager was unaware that the pharmacy needed clarification. The resident reported that the medication, intended to help regulate blood sugars and assist with weight loss, was not actually administered until weeks after it was first ordered.
A resident with CAD, HTN, DM, and prior CVA, who had moderately impaired cognition but was independent with dressing, footwear, and hygiene, was not provided appropriate foot care or podiatry services despite having thick, overgrown toenails causing pain with walking and shoe wear. A nurse conducting a weekly skin assessment noticed the long toenails but did not document the finding or initiate a podiatry referral because the resident had not complained. The resident was not placed on the podiatry schedule, and no podiatry consults were documented. NAs, who provided only set-up assistance for bathing and allowed the resident to dress and apply socks independently, reported they had not seen the toenails and had not been told of discomfort. Later observations by nursing staff and the wound nurse confirmed the toenails were excessively long and required podiatry trimming.
A resident with type 2 DM and recent significant weight gain was started on semaglutide once weekly, but the order entered into the EMR contained incomplete dosage information, and the verifying nurse sent it to the pharmacy without correction. The pharmacist reported multiple unsuccessful attempts by phone, fax, and email to obtain clarification so the drug could be dispensed, while nursing staff noted the medication was not available in the med room and assumed it had not yet been delivered, without contacting the pharmacy or consistently notifying the provider. As a result, the ordered semaglutide was not supplied or administered as intended, and the order was later discontinued.
Surveyors found an unopened vial of Lorazepam 2 mg/mL past its expiration date stored in a locked bin in a medication room refrigerator. A medication aide confirmed the expiration date and reported uncertainty about who is responsible for checking the room for expired meds, believing night shift staff only monitor refrigerator temperatures and that the Pharmacist visits monthly. The DON stated the Pharmacist checks for expired meds monthly and that nurses are expected to remove discontinued meds and place them in pharmacy return containers. The Administrator reported that nurses should review medication orders each shift, send back discontinued meds, and check carts for expired and discontinued meds before administration. The Pharmacist indicated he conducts monthly med pass observations, a team member checks the medication room every other month for expired meds and stock, and that the facility should not rely solely on pharmacy visits to identify expired medications.
A resident with type 2 DM had an order for weekly subcutaneous semaglutide to help regulate blood sugars and assist with weight loss, but the drug was not available for multiple scheduled doses. An RN documented on the MAR that the medication was administered on one date and refused on another, even though she later stated the medication was not available and was not given on those dates. The resident, who was cognitively intact, reported that the medication was not actually started until a later month. The pharmacist indicated the initial order lacked dosage information and that semaglutide was delivered only after a corrected order was received, while the Administrator stated she was unaware the medication had not been administered and that non-administration should be documented accurately.
A Treatment Nurse failed to follow the facility’s infection control policy requiring glove changes and hand hygiene between dirty and clean steps of wound care for three residents with pressure ulcers and surgical wounds. For each resident, the nurse cleaned the wound with gauze and wound cleanser, then, without changing gloves or performing hand hygiene, proceeded to apply topical agents, dressings, and wraps. The nurse later acknowledged awareness of the required glove-change and hand hygiene steps but stated she became nervous while being observed. The IP and DON both confirmed that the nurse should have changed gloves and performed hand hygiene between wound cleansing and application of clean dressings.
A resident receiving insulin injections twice daily was not having her blood sugar levels monitored due to a lapse in communication and order entry in the eMAR. The Nurse Practitioner discontinued the sliding scale insulin but did not intend to stop FSBS checks. Staff were unaware of the discontinuation, and the facility lacked a policy for FSBS use in diabetics.
A survey of a medication cart revealed deficiencies in insulin pen labeling and storage. Opened Glargine and Novolog insulin pens were undated, and Insulin detemir and Lispro pens were expired. An unopened insulin pen was improperly stored outside the refrigerator. Interviews with a nurse and the DON confirmed these issues, indicating lapses in medication management protocols.
Failure to Notify Provider When Ordered Medication Not Administered
Penalty
Summary
The deficiency involves the facility’s failure to notify the Physician/Physician Assistant when a resident did not receive a prescribed medication. A resident admitted with type 2 diabetes had an order written on 11/25/25 for weekly subcutaneous semaglutide (0.25 mg or 0.50 mg) on Mondays. The MAR showed the medication as administered on 12/01/25 at 8:00 AM, refused by the resident on 12/08/25, and not administered on 12/15/25 due to awaiting delivery from the pharmacy, with the order discontinued on 12/22/25. Review of the medical record revealed no documentation that the Physician/Physician Assistant had been notified that the semaglutide was not administered as ordered. During interview, the nurse assigned to the resident stated the semaglutide was not available in the medication room on 12/01/25, 12/08/25, or 12/15/25 and that she did not administer the medication on those dates. She acknowledged documenting in error on the MAR that the medication was given on 12/01/25 and that the resident refused it on 12/08/25, and stated she should have documented that the medication was unavailable. She reported that she generally notified providers when a resident did not receive a prescribed medication but could not recall notifying the Physician Assistant in this case. The Physician Assistant reported entering the semaglutide order in the EMR on 11/25/25 and notifying a nurse that it was ready to be sent to the pharmacy, and stated she was not informed that the order sent lacked a dose or that the medication was not delivered until 12/29/25. The Administrator stated that the Physician/Physician Assistant should be notified whenever a resident is not receiving a prescribed medication, whether due to unavailability or refusal.
Failure to Clarify Semaglutide Order and Obtain Medication as Prescribed
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a new medication order for semaglutide was clarified and processed so the medication could be obtained and administered as ordered. A physician assistant evaluated Resident #75, who had type 2 diabetes, weight gain of approximately 15 pounds in three months, and varying blood sugars, and entered an order on 11/25/25 for semaglutide to be given weekly. The order in the physician orders and MAR was written as semaglutide (0.25 mg or 0.50 mg) weekly, and the MAR showed an entry that it was administered on 12/01/25, refused on 12/08/25, and unavailable on 12/15/25, with discontinuation on 12/22/25 and a new order on 12/29/25 for semaglutide 0.25 mg weekly. The resident’s MDS documented that she was cognitively intact, had an active diagnosis of diabetes mellitus, and was receiving insulin injections daily, and her care plan identified risk for hypo- and hyperglycemic episodes with monitoring interventions. Resident #75 reported that semaglutide was ordered in late November to help regulate blood sugars and assist with weight loss but was not actually administered until January, and she did not question the delay because she believed it usually took a while for the facility to obtain new medications. She confirmed refusing the first two January doses because she had questions for the physician assistant about possible reactions, and stated that the medication was administered as ordered later in January. Nurse #2, who was assigned to the resident on day shift, stated that semaglutide was not available on three December dates and therefore was not administered, and she could not recall whether she notified the unit manager or provider about the unavailability. She further acknowledged that she documented in error on the MAR that the medication was administered on one date and refused on another, and that she should have documented that the medication was unavailable. Nurse #1, the unit manager, explained that new medication orders are entered into the EMR, verified, and sent electronically to the pharmacy, and that she verified the semaglutide order and sent it to the pharmacy but was not aware that the dose was missing or that clarification was needed. The pharmacist reported that the facility sent an order for semaglutide without dosage information and that the former DON was notified on four separate dates that the order needed to be resent with the dose before the medication could be dispensed and delivered. The pharmacist stated that a new order specifying semaglutide 0.25 mg weekly was finally sent on 12/29/25 and the medication was delivered on 12/31/25. The physician assistant and medical director both stated they were not informed that the pharmacy required clarification or that the resident had not received semaglutide until mid-January, and both stated that medications should be administered as ordered. The administrator stated that when the pharmacy notified the former DON that the order lacked dosage information, the former DON should have clarified the order with the physician assistant and sent an updated order to the pharmacy so the medication could be obtained and administered as ordered.
Failure to Assess and Arrange Podiatry Care for Long, Painful Toenails
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate foot care and arrange podiatry services for a resident with multiple medical conditions, including CAD, hypertension, diabetes mellitus, and a history of CVA. The resident’s care plan, revised on 12/07/25, identified the need for extensive and total staff assistance with ADLs, including grooming and personal hygiene, while also noting that the resident ambulated independently with a cane. A quarterly MDS documented that the resident had moderately impaired cognition but was independent with dressing, footwear, personal hygiene, and ambulation with a walker, and did not reject care. Despite these assessments, the resident’s weekly skin assessment dated 02/05/26, completed by Nurse #1, contained no notation that the toenails were long, thick, or required trimming or podiatry referral, even though Nurse #1 later acknowledged she had noticed the long toenails at that time but did not document them because the resident had not complained. Further record review showed the resident was not on the February 2026 podiatry clinic schedule, and there were no podiatry consultation reports or notes from admission through 02/11/26. During an observation and interview on 02/08/26, the resident removed his socks and displayed thick, long toenails on the left foot extending past the nail bed, reporting pain when putting on shoes and walking, and stating he had not reported this because he did not want to bother staff, although he believed staff had seen them. Subsequent observations with Nurse #1 and the Wound Care Nurse confirmed the toenails were long, thick, and in need of podiatry trimming, with the left hallux nail curved to the side and measured lengths up to 3 cm. Nursing assistants reported they had not seen the resident’s toenails because he dressed himself, wore his socks, and preferred to bathe in his room with only set-up assistance, and he had not voiced discomfort to them. The DON stated that NAs should have alerted nurses and that nurses should have assessed toenails during weekly skin assessments and placed the resident on the podiatry list when needed, while the Administrator reported she had not been informed of the issue and that the resident had not approached her with concerns.
Failure to Clarify and Obtain Ordered Diabetic Medication From Pharmacy
Penalty
Summary
The deficiency involves the facility’s failure to ensure a complete and clear prescription for a new diabetic medication and to respond to repeated pharmacy requests for clarification, resulting in the medication not being dispensed. A resident with type 2 diabetes, weight gain of approximately 15 pounds over three months, and noncompliance with a diabetic diet was evaluated by a Physician Assistant, who ordered semaglutide 0.25 mg once weekly to help regulate blood sugars and assist with weight loss. The physician order entered on 11/25/25 in the EMR read semaglutide (0.25 mg or 0.50 mg) to be administered subcutaneously once a week on Mondays, which the pharmacist later identified as lacking complete dosage information. The order was verified and sent to the pharmacy by the unit manager nurse on 11/28/25 without recognizing the incomplete dosage. The MAR showed one administration documented in error, one refusal, and one missed dose due to awaiting pharmacy delivery, and the order was discontinued on 12/22/25. Nursing staff did not ensure the medication was available or follow up appropriately when it was not in the medication room. The nurse assigned to the resident on the relevant dates reported that semaglutide was not available and that she assumed the new medication had not yet been delivered; she did not call the pharmacy to check the status and did not recall notifying the Physician Assistant, though she stated the unit manager nurse was aware. The unit manager nurse stated she believed the medication was not delivered because it was unavailable and did not follow up with the pharmacy. The pharmacist reported that the pharmacy attempted to contact the facility multiple times by phone, fax, and email on four separate dates to obtain clarification of the semaglutide order so it could be dispensed, but the facility did not provide a corrected order until 12/29/25. The Administrator stated she did not receive the pharmacy’s emails and could not confirm whether the former DON had received or acted on them, while also indicating that when a medication is not available, the assigned nurse, unit manager, and/or DON should contact the pharmacy or send a refill request in the EMR to ensure medications are available and administered as ordered.
Expired Lorazepam Vial Found in Medication Room Refrigerator
Penalty
Summary
Surveyors identified a deficiency in medication storage and monitoring when an unopened vial of Lorazepam 2 mg/mL with an expiration date of August 2025 was found in a locked bin in medication room [ROOM NUMBER]'s refrigerator. The observation occurred in the presence of a medication aide, who verified the expiration date on the vial. The report does not identify any specific resident associated with this medication or any clinical use at the time of the survey. During interviews, the medication aide stated she was unsure who was responsible for checking the medication room for expired medications and believed night shift staff only checked the refrigerator temperature. She also indicated that the Pharmacist visited monthly but needed to confirm details with the DON. The DON reported that the Pharmacist visits once per month to check for expired medications and that nurses are expected to remove discontinued medications from carts or the refrigerator and place them in pharmacy return containers. The Administrator stated that expired medications should be sent back to the pharmacy and that each nurse should check medication orders each shift and remove discontinued medications, as well as check carts for expired and discontinued medications before administering medications. The Pharmacist reported that he visits monthly for medication administration observations and that a team member visits every other month to check the medication room for expired medications and stock needs, and further stated that the facility should not rely on pharmacy visits to review medication stock for expired medications because pharmacy staff may not check the stock every month.
Inaccurate MAR Documentation for Ordered Semaglutide Therapy
Penalty
Summary
The facility failed to maintain accurate medication administration records for a resident with type 2 diabetes who had an order for semaglutide. Physician orders and the MAR showed an order dated 11/25/25 for semaglutide (0.25 mg or 0.50 mg) to be given subcutaneously once weekly on Mondays. The MAR reflected that semaglutide was administered on 12/01/25 at 8:00 AM, was refused by the resident on 12/08/25, and was not given on 12/15/25 due to awaiting delivery from the pharmacy, all documented by the same nurse. However, the resident, who was assessed as cognitively intact on a quarterly MDS, reported that although the PA ordered semaglutide on 11/25/25 to help regulate blood sugars and assist with weight loss, the medication was not actually administered until January 2026. In an interview, the nurse assigned to the resident on day shift stated that semaglutide was not available on 12/01/25, 12/08/25, or 12/15/25 and was not administered on those dates. She acknowledged that her MAR entries indicating administration on 12/01/25 and refusal on 12/08/25 were erroneous and that she should have documented the medication as unavailable. The pharmacist reported that the original order sent on 11/25/25 lacked dosage information, and a new order specifying semaglutide 0.25 mg was later sent, after which the medication was delivered. The Administrator stated she was not aware that the resident had not received semaglutide as ordered because it was not delivered and unavailable, and confirmed that when a medication is not administered it should be documented accurately in the resident record and on the MAR.
Failure to Follow Hand Hygiene and Glove-Change Protocol During Wound Care
Penalty
Summary
The deficiency involves the facility’s failure to follow its own infection prevention and control policy during wound care for three residents. The facility’s policy, revised on 10/28/24, required staff to perform hand hygiene before and after donning gloves, to change gloves when moving from dirty to clean tasks, and to always change gloves between residents. During wound care for Resident #4, the Treatment Nurse was observed with a gown already on, sanitized her hands, and donned clean gloves. The dressing had already come off earlier during incontinence care. She cleaned the coccyx pressure ulcer with gauze soaked in wound cleaner and, without changing gloves or performing hand hygiene, applied Santyl ointment, wet-to-moist Dakin’s solution, packed the wound bed, and applied a super absorbent pad before discarding supplies and removing PPE. During wound care for Resident #62, the Treatment Nurse donned a clean gown and gloves, removed the old dressing from the resident’s right ankle, and cleaned the wound with gauze soaked in wound cleaner. While still wearing the same gloves used for cleaning, she applied an axeroform petrolatum dressing to the wound. She then collected and discarded the supplies, removed her gown and gloves, and washed her hands with soap and water only after the entire procedure was completed, without an interim glove change or hand hygiene between the dirty and clean portions of the wound care. For Resident #103, the Treatment Nurse entered the room wearing a gown, washed her hands, and put on gloves before removing the dressing from a right heel pressure ulcer. She then removed her gloves, used hand sanitizer, donned new gloves, and cleaned the ulcer with gauze soaked in wound cleaner. Without removing gloves or performing hand hygiene, she patted the ulcer dry with gauze, applied collagenase ointment with a cotton swab, covered the wound with calcium alginate and an abdominal pad, and wrapped the foot. After removing gloves and using hand sanitizer, she donned new gloves and removed the dressing from a surgical wound with staples on the resident’s left foot, then again removed gloves, sanitized her hands, and applied new gloves before cleaning the wound. She proceeded to cover the left foot wound with an abdominal pad and wrap it with gauze without changing gloves or performing hand hygiene between cleaning and dressing application. In interviews, the Treatment Nurse, Infection Preventionist, and DON all acknowledged that gloves should have been changed and hand hygiene performed between cleaning the wounds and applying clean dressings for all three residents.
Failure to Monitor Blood Sugar Levels in Insulin-Dependent Resident
Penalty
Summary
The facility failed to monitor a resident's blood sugar levels despite the resident receiving insulin injections twice daily. The resident, who was cognitively intact and required substantial assistance for most activities of daily living, expressed concern that her blood sugar was no longer being checked. She received 14 units of insulin in the morning and 16 units in the evening, but the staff had stopped checking her blood sugar, leading to episodes of increased sleepiness. The issue arose when the Nurse Practitioner discontinued the resident's sliding scale insulin order but did not intend for the finger-stick blood sugar (FSBS) checks to be discontinued. However, the FSBS checks were inadvertently stopped due to the way orders were entered into the electronic Medication Administration Record (eMAR). The facility's staff, including nurses and the consulting pharmacist, were unaware that the FSBS checks had been discontinued, and the resident's blood sugar levels had not been monitored since the sliding scale insulin order was discontinued. Interviews with the facility's staff revealed a lack of awareness and communication regarding the discontinuation of FSBS checks. The Director of Nursing and the Administrator were also unaware of the lapse in monitoring. The facility did not have a policy regarding FSBS use for diabetics, and the Medical Director mentioned that residents were assessed on a case-by-case basis for FSBS orders, with some consideration being given to using HbA1c levels for monitoring instead.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to adhere to proper medication labeling and storage protocols for insulin pens, as observed during a survey of the Hall A medication cart. Specifically, the survey revealed that opened Glargine and Novolog insulin pens were not dated, and an opened Insulin detemir flexpen and Lispro insulin pen were past their expiration dates based on the open dates of 08/23/2024 and 09/24/2024, respectively. Additionally, an unopened insulin pen was improperly stored in the medication cart instead of the refrigerator, contrary to the manufacturer's instructions. Interviews with Nurse #1 and the Director of Nursing (DON) confirmed the deficiencies. Nurse #1 acknowledged the oversight in dating the insulin pens and the presence of expired pens. The DON reiterated that all insulin pens should be labeled with an open date and a 28-day expiration date, and that unopened pens should be refrigerated. The DON also stated that it was the responsibility of all nurses to check for expired medications in the carts, highlighting a lapse in the facility's medication management practices.
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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