Salisbury Rehabilitation And Nursing Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Salisbury, North Carolina.
- Location
- 635 Statesville Boulevard, Salisbury, North Carolina 28144
- CMS Provider Number
- 345115
- Inspections on file
- 29
- Latest survey
- January 2, 2026
- Citations (last 12 mo.)
- 17 (1 serious)
Citation history
Health deficiencies cited at Salisbury Rehabilitation And Nursing Center during CMS and state inspections, most recent first.
A resident with cognitive impairment and a history of agitation was allowed unsupervised access to a courtyard, where he climbed onto the facility's roof after becoming upset about a potential move to a secured unit. Staff observed the resident on the roof and called the fire department for assistance. Prior to the incident, increased agitation and unsafe behaviors had been noted, but the resident's care plan and supervision level were not updated accordingly. The facility also failed to complete required smoking assessments for another resident.
Two residents experienced misappropriation of their prescribed Oxycodone when medication cards containing narcotic tablets went missing from locked medication storage. Staff discovered the discrepancies during routine narcotic counts, but documentation and narcotic counting procedures were not consistently followed, and the pharmacy was not notified of the missing medications. The responsible party for the missing narcotics could not be identified.
Two residents experienced separate incidents of missing oxycodone from the locked narcotic drawer, and staff identified that full or partial medication cards of oxycodone were no longer present during narcotic counts. In the first case, documentation showed two cards of oxycodone were delivered, but only one was found; the DON reported the loss initially but did not complete or provide evidence of a required 5‑day investigation report to the State Agency. In the second case, a hospice resident’s remaining oxycodone tablets were discovered missing during a count requested by a hospice nurse, and although the loss was reported internally to the DON, she did not submit the required 24‑hour or 5‑day reports to the State Agency or notify APS, law enforcement, or DEA, believing additional reporting was unnecessary after the first incident.
Multiple residents with prior Level I PASRR status were later diagnosed with serious mental disorders such as schizophrenia, bipolar disorder, dementia with behavioral disturbance, psychosis, and severe depression, and were receiving ongoing psychiatric treatment, including antipsychotic medications and regular psychiatric NP follow-up. Despite pre-admission PASRR instructions to resubmit for Level II upon new mental health diagnoses or significant changes in condition, the facility did not submit Level II PASRR requests for these residents. The MDS nurse identified residents with new psychiatric diagnoses and provided a handwritten list of 25 residents needing PASRR referrals to Social Services and the DON, but several residents remained on the list without completed referrals, and no documentation of Level II PASRR determinations was found in their records. Interviews with the MDS nurse, Social Work Director, and DON confirmed that the process to initiate and complete Level II PASRR evaluations after diagnosis changes was not carried out for these residents.
Surveyors found that the facility failed to consistently remove expired and unlabeled food items from the dry storage room, walk-in cooler, and nourishment rooms. In dry storage, multiple expired products and dented canned vegetables were stored with regular stock, and numerous single-use dressing packets were kept in mislabeled or unlabeled bins with no way to verify expiration dates. In the walk-in cooler, several large containers of chicken salad were past the manufacturer’s expiration date but remained available for use. In the 100 and 200 hall nourishment rooms, opened containers of nutritional supplements, thickened beverages, and sweet tea lacked opening dates despite manufacturer time-use limits, and several personal food items were unlabeled. The Dietary Manager and nursing staff shared responsibility for monitoring and labeling, but there was no designated schedule for checks, and assigned staff did not consistently remove outdated, mislabeled, or unlabeled items.
A resident assessed as safe for unsupervised smoking was prevented from accessing the smoking area after 8:00 PM due to facility policy, despite their care plan allowing independent smoking and the resident's expressed preference to smoke later in the evening. Staff enforced this restriction based on prior instructions and concerns about weather, limiting the resident's right to self-determination.
Survey results were not readily accessible because the survey binder, though referenced by a sign at the front desk, was kept behind the receptionist desk in a restricted area that residents and visitors could not access without asking. Several residents reported not knowing where the survey results were located. Staff interviews confirmed the book had always been stored behind the desk, that individuals were not allowed in that area, and that they had to request to see it. Leadership acknowledged awareness that survey results were required to be continuously available without residents or visitors having to ask.
A resident with cognitive impairment, emphysema, prior stroke, and a history of repeated falls was repeatedly observed in a reclining Broda wheelchair positioned at angles up to approximately 130 degrees, during which the resident at times attempted to sit up or stand. The readmission assessment left device and restraint sections incomplete, and the EMR contained no MD order or documentation identifying or assessing any restraint use. NAs and a nurse reported that the chair was reclined specifically to prevent falls, acknowledging the resident could get out of the chair when upright, while the rehab manager and DON recognized that reclining beyond about 110 degrees constituted a restraint and that the chair was not intended to be used that way. The MD stated there was no known medical indication for using the chair at a 130-degree recline and did not support restricting the resident’s movement.
A resident with dementia and alcohol abuse, assessed as severely cognitively impaired, was transferred to the hospital for evaluation after aggressive behavior, exit seeking, and attempts to access the facility roof. On the same day as a discharge-return-anticipated assessment, the social worker informed the guardian that the resident was being issued a 30‑day discharge notice and that the facility could no longer manage his behaviors, while the administrator signed a transfer/discharge notice citing danger to others. The guardian reported being told the resident was suicidal and that the facility would not accept him back, although the resident later stated he was not suicidal and only wanted to leave. The DON and nursing staff indicated the resident became more agitated after being told he would be moved to a secured dementia unit, that he needed 1:1 supervision or secured placement, and that the facility declined his return because he would not agree to transfer to the secured unit or wear a wander guard, leading to prolonged hospitalization until alternate placement was found.
A resident with non-Alzheimer’s dementia, anxiety disorder, bipolar disorder, and a psychotic disorder had a PASRR Level II Determination Notification indicating a halted Level II determination due to a primary dementia diagnosis, with a PASRR number ending in H. However, the resident’s most recent comprehensive significant change MDS assessment was coded as not having a PASRR Level II status. During interviews, the MDS nurse acknowledged the MDS coding was incorrect and that the resident should have been identified as PASRR Level II, and the DON stated she expected MDS assessments to be accurate.
A resident with multiple psychiatric and cognitive diagnoses, including dementia, had an existing PASRR Level II determination and later experienced a significant change in condition, including initiation of hospice care, as documented on a comprehensive MDS and CAA for cognitive loss/dementia. Although the MDS nurse recognized that this resident, listed as a PASRR Level II case, should have been referred for a PASRR re-evaluation after the significant change assessment, no referral was made. The Director of Social Services confirmed she did not submit a PASRR re-evaluation request, stating she believed it was unnecessary because the resident already had a Level II PASRR status, resulting in the facility’s failure to notify the appropriate authorities for a required PASRR Level II re-evaluation.
A resident with emphysema, prior CVA, and a history of repeated falls was readmitted, and staff completed a re-admission assessment that captured clinical and risk information but did not generate a baseline care plan. The DON and Unit Manager confirmed that the admitting nurse used the wrong assessment form, which lacked the baseline care plan component with focus areas, goals, and interventions, and a comprehensive care plan was not initiated until several days later and then only addressed nutrition.
A resident with emphysema, prior cerebral infarction, repeated falls, cognitive impairment, and probable inadequate intake was readmitted after a hospital stay with discharge instructions for a pureed diet with thin liquids. Nursing completed a re-admission assessment and a Unit Manager filled out a communication form to Dietary specifying a regular diet with pureed textures and thin liquids, but no provider diet order was entered into the EMR at admission. Despite this, the resident was observed receiving and consuming pureed meals at breakfast and lunch. The Dietary Manager, Regional Dietary Manager, Unit Manager, and DON all confirmed that a provider diet order was missing from the EMR and that it should have been entered upon admission.
A resident with severely impaired cognition, total dependence for ADLs, and an indwelling catheter for neurogenic bladder was observed in bed with the catheter drainage bag lying on the floor, despite a care plan requiring proper catheter positioning. A NA reported she had been taught to hang the bag on the bed frame but said it often slipped off when the bed was kept low. When a unit manager attempted to rehang the bag, it still touched the floor, and leadership, including the ADON and DON, confirmed that catheter drainage bags were expected to remain off the floor and that staff had been educated on this requirement.
A resident with COPD and anemia experienced low O2 saturation and was started on O2 via nasal cannula after a nurse contacted a provider, with documentation in a progress note that the provider ordered 2 L/min O2 later increased to 3 L/min. The resident was repeatedly observed on 3 L/min O2 and had provider notes describing upper respiratory infection symptoms, low O2 saturations, and initiation of oxygen, antibiotics, and nebulizers, yet no corresponding oxygen order was entered into the EMR over multiple days. The unit manager confirmed that the nurse documented receiving the oxygen order but did not create the required EMR order.
Surveyors identified a 7.6% medication error rate when a resident with COPD/asthma did not receive a scheduled morning dose of Breo Ellipta because the prior inhaler had expired and been removed from the cart and a replacement had not yet arrived, and when a nurse prepared an Insulin Lispro pen for another resident without initially priming it as required by the manufacturer’s instructions, only acknowledging and correcting this after being questioned; the DON confirmed expectations that medications be available as ordered and that staff follow clinical guidelines for administration.
The facility failed to ensure that daily nurse staffing sheets accurately reflected the actual nursing staff working across multiple days and shifts. Comparison of internal schedules with posted staffing sheets showed repeated discrepancies in the numbers of RNs, LPNs, CNAs, and CMAs listed for various shifts. Staff interviews revealed that a staff coordinator and receptionists posted the sheets, while nursing staff were sometimes expected to revise them for callouts or schedule changes. One receptionist reported that nursing staff did not always communicate changes, and another stated she had never been educated or instructed to revise the postings. The administrator stated that the staff coordinator was responsible for accurate postings and that he expected the sheets to be updated to show correct staffing for each shift.
A resident admitted with fractures to her left knee and right ankle did not receive the prescribed Oxycodone for pain management due to the absence of a prescription from the hospital. Instead, she was given Acetaminophen, which did not adequately relieve her pain. Staff interviews revealed that the facility's on-call service would not provide a narcotic prescription without one from the hospital, and the nursing staff did not contact the Physician or Nurse Practitioner to obtain the necessary prescription.
A resident with severe cognitive impairment and an indwelling urinary catheter missed a scheduled urology appointment for a catheter change. The appointment was not rescheduled, and the resident was later hospitalized with sepsis and a urinary tract infection. The facility's Appointment Coordinator and Urology Clinic's Scheduler provided conflicting information about the appointment's cancellation and rescheduling. The resident's decline was attributed to existing health conditions, and they were transferred for palliative care.
A resident admitted with leg fractures did not receive prescribed Oxycodone due to the facility's failure to obtain a necessary prescription. Instead, the resident was given Acetaminophen, which did not relieve her pain. The on-call provider would not issue a narcotic order without a hospital prescription, preventing the pharmacy from releasing the medication from the emergency back-up system.
The facility's kitchen was found to have a malfunctioning sink drain and leaking pipe, causing standing water on the floor. Additionally, dusty ceiling vents and improperly stored cereal bags were observed. Staff interviews revealed that maintenance had been notified of the sink issue, but it remained unresolved. The Maintenance Director admitted to previous repair attempts, and the Administrator was unaware of the ongoing problem.
The facility failed to maintain sanitary conditions around the outdoor trash receptacle area, with observations revealing loose garbage and debris on multiple occasions. Interviews with staff indicated ongoing issues and uncertainty about responsibility for cleaning the area. The Administrator acknowledged the problem and expected housekeeping and kitchen staff to maintain cleanliness.
The facility failed to conduct quarterly smoking assessments for two residents, one cognitively intact and the other moderately impaired, both of whom were allowed to smoke unsupervised. Despite being identified as smokers in their care plans, assessments were not completed for over a year. The nursing staff was responsible for these assessments, but the oversight was not recognized by the Administrator until the survey.
Failure to Prevent Accident Hazard Due to Inadequate Supervision of Cognitively Impaired Resident
Penalty
Summary
A deficiency occurred when a resident with cognitive impairment, alcohol-induced dementia, and a court-appointed guardian was not provided with effective supervision, resulting in a serious incident. The resident, who had a history of confusion, agitation, and impaired judgment, was allowed unsupervised access to an enclosed courtyard where he was considered a safe smoker. On the day of the incident, the resident became upset after being told by staff that he would be moved to a secured unit. Subsequently, he stacked patio furniture, climbed onto an awning, and then accessed the facility's roof. Staff observed the resident running and sitting on the edge of the roof, prompting the fire department to be called for his safe removal. Prior to this event, the resident had not exhibited wandering or exit-seeking behaviors, but staff had noted increased agitation and unsafe behaviors, including attempts to take his non-smoking roommate outside to smoke. Despite these observations and discussions with the guardian about escalating behaviors and the potential need for a higher level of care, the resident remained in the unsecured unit. The resident's care plan had not been updated to reflect the increased risk, and he was not placed under enhanced supervision or restricted from unsupervised courtyard access until after the incident occurred. Additionally, the facility failed to complete a smoking assessment on admission and quarterly for another resident to determine if independent smoking was safe or if supervision was required. The lack of timely reassessment and supervision for residents with cognitive impairment and behavioral changes contributed to the occurrence of the incident and the identified deficiency.
Removal Plan
- Resident #120 was placed on enhanced supervision and restricted from unsupervised courtyard access after the incident.
- Resident #120 was reassessed and changed from a safe smoker to a supervised smoker.
- Resident #120 was relocated to a room closer to the nurses' station for increased observation.
- All residents with cognitive deficits and physical capabilities were assessed for wandering, change in behavior, increased agitation, and problematic behaviors.
- Wander guard transmitters were placed on all residents identified as having the ability to wander.
- The Interdisciplinary Team reviewed all residents to identify those with wandering or exit-seeking behavior.
- Staff members were assigned as wandering resident monitors on duty to monitor wandering residents and points of egress.
- All staff received in-service training on supervision of wandering residents, continuous observation, escalation of concerns, and environmental risk identification.
- Staff were instructed to relocate residents displaying exit-seeking or wandering behavior to the secure unit and notify the DON for evaluation.
- All employees were re-hired by new ownership and required to complete dementia and behavior management training to be eligible for rehire.
- All new hires receive training on dementia and care of wandering/behavioral residents during orientation and thereafter.
- Unsupervised courtyard access was restricted for residents with wandering or unsafe behaviors.
- Designated staff monitor the courtyard during resident use.
- Routine environmental rounds are conducted to identify elevated surfaces and climbing risks.
- Behavioral escalation triggers are incorporated into care planning.
- Nurse managers are to be notified immediately for new agitation, pacing, wandering, or exit-seeking behavior; a wandering assessment is completed, wander guard placed, provider and responsible party notified, and care plan updated.
- Residents with new wandering or exit-seeking behaviors are discussed in clinical meetings.
- The DON is responsible for ensuring wandering assessments, notifications, wander guard initiation, and care plan updates are completed.
- A list of exit-seeking/wandering residents is updated and reviewed by the DON and Social Worker.
- Resident wandering assessments and nursing documentation are audited by the DON/ADON to identify residents with increased agitation, exit-seeking, or wandering behavior.
- Audits ensure residents with these behaviors have wander guards and appropriate care plan interventions.
- Audit results are discussed at the clinical At-Risk IDT Meeting and presented to the QAPI Committee for review and revision as needed.
- All residents are assessed for wandering and exit-seeking and with any significant change in condition.
- Education on facility processes for residents with increased agitation, pacing, exit-seeking, or wandering behavior is provided to all staff and reviewed.
Failure to Protect Residents from Misappropriation of Narcotic Medications
Penalty
Summary
The facility failed to protect residents from the misappropriation of narcotic medications, specifically Oxycodone, for two residents. For one resident, physician orders indicated a prescription for Oxycodone 5 mg twice daily, with two medication cards of 30 tablets each delivered to the facility. However, during a routine narcotic count, staff discovered that one of the medication cards was missing from the locked narcotic box in the medication cart. The medication administration records showed the resident consistently received the prescribed doses and did not report pain, but the missing card was not accounted for, and the receiving nurse had not signed the pharmacy delivery slip. For another resident, who had a PRN order for Oxycodone 5 mg, a medication card of 28 tablets was found missing from the locked narcotic drawer. The resident rarely used the Oxycodone due to an alternative prescription for liquid Morphine Sulfate, and the medication administration record confirmed no doses had been administered. The discrepancy was identified during a narcotic count conducted by a medication aide and a hospice nurse, who noted the absence of the medication card that had previously contained 28 tablets. Interviews with staff revealed that narcotic counts were not consistently performed according to facility policy, and documentation of the number of medication cards was incomplete on several occasions. The pharmacy was not notified of the missing medications, and staff involved in the counts were not suspended or drug tested during the investigation. The facility was unable to determine who was responsible for the missing narcotic medication cards.
Failure to Report Misappropriation of Narcotic Medications to Required Authorities
Penalty
Summary
The deficiency involves the facility’s failure to timely and completely report suspected misappropriation of narcotic medications to the State Agency and other required authorities. For one resident with immobility and contractures who had an order for oxycodone 5 mg twice daily, pharmacy documentation showed two 30‑tablet cards of oxycodone were delivered, but only one card (labeled 1 of 2) was present in the locked narcotic drawer when a medication aide and a nurse counted narcotics at shift change. The missing 30‑tablet card was reported to the DON, who stated she submitted a 24‑hour report to the State Agency and notified law enforcement, Adult Protective Services, and the contracted pharmacist. However, she could not produce a 5‑day investigation report or proof it was sent, and the State Agency did not receive it, contrary to the facility’s Abuse Policy requiring reporting of misappropriation to the State Agency, Adult Protective Services, and law enforcement within 24 hours and completion of a 5‑day investigation report. The deficiency also includes the facility’s failure to report another incident of missing narcotics for a hospice resident with osteoporosis and chronic pain who had PRN oxycodone 5 mg and scheduled morphine sulfate. Pharmacy delivery records showed oxycodone tablets were supplied, and a medication aide recalled 28 oxycodone tablets present in the locked narcotic drawer on a prior workday. When asked by a hospice nurse to count narcotics, the aide found that the oxycodone card with 28 tablets was no longer in the locked narcotics box and reported this to the DON. The DON acknowledged that she did not initiate a 24‑hour or 5‑day report to the State Agency and did not notify police, Adult Protective Services, or the DEA about the 28 missing oxycodone tablets, stating she believed additional reporting was unnecessary because she had already investigated the earlier missing oxycodone for another resident. The administrator stated the DON should have ensured required notifications were made for both residents’ missing narcotics.
Failure to Request Level II PASRR Evaluations After New Serious Mental Health Diagnoses
Penalty
Summary
The deficiency involves the facility’s failure to request Level II Preadmission Screening and Resident Review (PASRR) evaluations after new serious mental disorder diagnoses or significant changes in condition were identified for multiple residents who previously had Level I PASRR status. For one resident, a Level I PASRR completed prior to admission instructed that paperwork be resubmitted for a Level II evaluation if a new mental health diagnosis was suspected or if there was a significant change in condition. After admission, this resident was diagnosed with dementia with behavioral disturbance, schizophrenia, and anxiety, and was treated with olanzapine for schizophrenia, with ongoing psychiatric follow-up and consideration of gradual dose reduction. Despite these new diagnoses and ongoing psychiatric management, there was no documented evidence that a Level II PASRR evaluation was requested, and the resident’s name remained on an internal list of residents needing PASRR referrals without indication of completion. Another resident had a Level I PASRR completed prior to admission with the same instruction to resubmit for Level II if a new mental health diagnosis or significant change occurred. This resident was admitted with schizophrenia and later received additional diagnoses of severe depression, dementia, and bipolar disorder. Psychiatric notes documented that the resident was stable on the current regimen and would be seen routinely for schizophrenia, depression, and bipolar disorder. However, the medical record contained no documentation that a Level II PASRR evaluation was requested. The resident’s name also appeared on the handwritten list of residents needing PASRR Level II evaluations and was not crossed off, and facility staff could not provide a date when the submission would be completed. A third resident had a Level I PASRR completed prior to admission with instructions to resubmit for Level II if a new mental health diagnosis or significant change occurred. This resident was later diagnosed with psychosis, dementia, bipolar disorder, anxiety, and schizophrenia, and psychiatric documentation showed ongoing follow-up every four weeks for schizophrenia, bipolar disorder, and anxiety, including assessment for gradual dose reduction of psychiatric medications. Despite these multiple serious mental health diagnoses, there was no documented evidence of a Level II PASRR determination request, and the resident’s name remained uncrossed on the list of residents needing PASRR referrals. A fourth resident was admitted with a Level I PASRR status documented on an FL-2 form and a history of stroke; after admission, additional diagnoses of dementia with psychotic disorder, bipolar disorder, and unspecified psychosis were added. A significant change MDS assessment noted that bipolar disorder was diagnosed after admission and that a significant change in status assessment had been completed, yet the MDS still reflected a Level I PASRR status. The Director of Social Services confirmed this resident was on the list of those needing PASRR referral and that no referral had been initiated. Interviews with the MDS nurse, Social Work Director, and DON confirmed that residents with new mental health diagnoses or significant changes had been identified, but the process to submit Level II PASRR requests had not been carried out for these residents. Facility staff interviews further clarified the actions and inactions that led to the deficiency. The MDS nurse stated she understood that when a resident had a change in condition along with a new mental health diagnosis, she was to notify the Social Work Director for a Level II PASRR referral, and she had created and shared a handwritten list of 25 residents with new mental health diagnoses requiring referral. The Social Work Director reported that she was responsible for initiating Level I or Level II PASRR requests when notified by the MDS nurse of a significant change or new mental health diagnosis and acknowledged that the residents in question were on an audit list of names that still needed to be submitted for Level II evaluations. The list of 25 residents showed that the names of the affected residents were not crossed off, indicating that submissions had not been completed, and the Social Work Director was unable to provide dates when these submissions would occur. The DON, who had recently assumed the role, stated her understanding that Level II PASRR requests should be completed in a timely manner upon admission or readmission of residents with mental health diagnoses and whenever there was a change in condition or new mental health diagnosis, but she was not aware of the specific residents on the list and confirmed that the issue of missed PASRR screenings remained a concern.
Expired and Unlabeled Food Items in Storage, Cooler, and Nourishment Rooms
Penalty
Summary
The deficiency involves the facility’s failure to ensure food was procured, stored, and maintained in accordance with professional standards, including removal of expired and improperly stored items. In the dry goods storage room, surveyors observed multiple expired products, including thickened orange juice cups, animal crackers, ground coffee packets, and vegetable soup base. There were also numerous single-use salad dressing packets stored in bins that were either mislabeled or unlabeled, with no way to determine their expiration dates because the original boxes had been discarded. Additionally, a case of dented canned vegetables was stored on a regular shelf with other canned goods instead of in the designated area for dented items, despite posted signage instructing staff not to use dented items and to store them separately for return or credit. The Dietary Manager acknowledged responsibility for inspecting storage areas and checking for expired items but reported having no designated schedule for these checks. In the walk-in cooler, surveyors found three containers of chicken salad that were past the manufacturer’s expiration dates, including two full 5-pound containers and one half-full 5-pound container. These items remained in the cooler instead of being discarded or otherwise removed from circulation. The Dietary Manager stated that his standard practice was to dispose of expired cold foods in the garbage, indicating that the presence of these expired items in the cooler was inconsistent with his stated practice. This demonstrated a failure to consistently monitor and remove expired refrigerated food items intended for resident use. In the nourishment rooms on the 100 and 200 halls, surveyors observed multiple opened and partially used containers of nutritional supplements, thickened beverages, and sweet tea that were not labeled with the date they were opened, despite manufacturer guidelines requiring use within a specified number of days after opening when refrigerated. In the 200-hall nourishment room, there were also several personal food items, including partially eaten foods and fast-food items, that were not labeled. Similarly, in the 100-hall nourishment room, opened thickened lemonade and nutritional supplement containers lacked opening dates, and personal food items were unlabeled. The Dietary Manager reported he was responsible for checking nourishment refrigerators for expired items but had no designated schedule, and he stated that nursing staff were responsible for checking nourishment rooms and that any staff placing residents’ personal food in the refrigerators were responsible for labeling it with the resident’s name and the date placed in storage. A Unit Manager later stated that two staff assigned to the nourishment room task were responsible for removing outdated, mislabeled, or unlabeled items at the end of their shift and that the policy for food storage and labeling was posted, but acknowledged that unlabeled items had been present and removed.
Failure to Honor Resident Choice for Independent Smoking
Penalty
Summary
A resident who was cognitively intact and assessed as safe to smoke without supervision was not allowed to smoke at their preferred times. The resident's care plan and smoking assessment indicated that they could smoke independently and unsupervised. However, the facility restricted the resident from accessing the designated smoking area after 8:00 PM by locking the doors, despite the resident's expressed desire to smoke later in the evening. The resident reported this restriction to staff, and staff interviews confirmed that the policy of not allowing residents outside to smoke after 8:00 PM was enforced, even for those assessed as safe to smoke independently. Staff indicated that this restriction was due to instructions from department heads and concerns about cold weather, as well as a lack of available staff for supervised smokers. The Director of Nursing acknowledged that independent smokers should be allowed to smoke at their preferred times, and the Administrator was unaware of the restriction for independent smokers, attributing it to previous administration practices. The facility's actions failed to honor the resident's right to self-determination and choice regarding smoking, as required by their care plan and assessment.
Survey Results Not Readily Accessible to Residents and Visitors
Penalty
Summary
The facility failed to make survey results readily accessible to residents and visitors without requiring them to ask, as required. During a Resident Council meeting, multiple residents reported they did not know where the survey results were located. An observation showed a sign on the receptionist desk stating that the survey binder was located at the front desk, but the actual survey results book was kept behind the reception desk in a small room near the entrance. This area was restricted by walls and a desk, closed off to residents and visitors, and while the book was visible behind the receptionist, it was not within reach from the front of the desk. Interviews with two receptionists confirmed that the survey results book had always been kept behind the desk in a restricted area and that residents and visitors were not allowed behind the desk, but instead had to request access to review the book. The receptionists also described their work hours, indicating that access to the book depended on their presence. The ADON acknowledged she had not noticed that the survey results book was not in a public area and stated she was aware it needed to always be available without residents or visitors having to ask. The Administrator reported that the book had previously been placed in front of the desk but was moved behind the desk a few weeks earlier after residents had taken and misplaced it, and he acknowledged knowing that the survey results needed to be always available and not require a request to view.
Improper Use of Reclining Wheelchair as Undocumented Restraint
Penalty
Summary
The deficiency involves the facility’s failure to identify and manage a reclining Broda wheelchair as a physical restraint when used in a manner that restricted a resident’s ability to rise independently, and without medical justification or required documentation. The resident involved had emphysema, a history of cerebral infarction, repeated falls, and cognitive impairment, being oriented to person only and confused. On readmission, the Nursing Re-admission Assessment Tool completed by a nurse included sections for Device Assessment and Restraint Identification, but these sections were left blank. The resident’s EMR contained no physician orders for any device that would restrict movement and no documentation of identification, assessment, or use of a restraint. Surveyors observed the resident on multiple occasions seated in a reclining Broda wheelchair at varying back angles, including approximately 110 degrees and 130 degrees. At several observations when the chair was reclined to about 130 degrees, the resident appeared to be attempting to sit up or stand by pulling her upper body forward, including while near the nursing station, in a hallway, and in her room. At other times, when the chair was reclined to about 110 degrees, the resident appeared comfortable, content, and able to feed herself or participate in activities. During therapy, the same chair was observed in an upright position while the resident engaged in therapeutic exercise. Interviews with staff revealed that the chair was intentionally reclined to prevent falls rather than for a documented medical treatment purpose. Two NAs stated that the chair was reclined that far because the resident was at high risk for falls and agreed that the recline was intended to prevent her from falling, noting it could be less reclined when someone was close by. A nurse reported that during a prior admission the resident used the same type of reclined wheelchair, that the resident had multiple falls, and that the resident could get out of the wheelchair when it was in a normal sitting position, which is how she fell. The Rehab Therapy Manager acknowledged that reclining the chair beyond approximately 110 degrees would make it a restraint and stated that the 130-degree position was not typically used except for rest. The DON stated she understood that a 130-degree recline would be considered a restraint and that the Broda chair was never to be used as a restraint. The Medical Director reported he was not aware of any medical symptoms that would warrant use of a 130-degree reclined wheelchair for this resident and did not recommend restricting or restraining the resident’s movements.
Failure to Readmit Hospitalized Resident After Transfer for Behavioral Concerns
Penalty
Summary
The deficiency involves the facility’s failure to allow a resident to return following a hospital transfer, despite the transfer/discharge being identified as a discharge-return-anticipated. The resident had diagnoses of alcohol abuse and dementia and was assessed as severely cognitively impaired. A quarterly MDS and a discharge-return-anticipated MDS were completed, and on the same day the social worker documented that the guardian was notified the resident was being issued a 30‑day discharge notice for behaviors the facility stated it could not manage, and that the facility was going to proceed with involuntary committal because it could no longer keep the resident safe. Later that day, a nurse documented that the resident was transferred to the hospital for evaluation after aggressive behavior and extreme exit seeking, and that the resident was calm at the time of discharge. A written Nursing Home Notice of Transfer/Discharge, signed by the administrator, cited endangerment to the safety of individuals in the facility due to the resident’s clinical or behavioral status and indicated the guardian was notified of the transfer. Interviews and record review showed that the resident had previously climbed onto the facility roof and later attempted again by stacking lawn furniture in the courtyard. The social worker reported that the guardian was told the facility could no longer handle the resident’s behaviors and that he was sent to the hospital after a second roof attempt. The guardian stated she had not been informed of the first roof incident, but had been told previously that the resident was pushing other residents in wheelchairs and that the facility wanted to move him to a secured dementia unit, which she refused. The guardian reported being told by the social worker that the resident was sent to the hospital because he was suicidal and that the facility refused to accept him back on the grounds that they were unable to keep him from harming himself. The resident later told the guardian from the hospital that he was not suicidal and just wanted to leave the facility. Nursing and administrative staff interviews further described the events leading to the transfer and the refusal to readmit. A nurse stated the resident had always walked around the facility and had not attempted to leave until he was told he was being moved to the secured dementia unit, after which he became more agitated and was perceived as potentially harmful to others, though not suicidal. The nurse stated the resident needed one‑to‑one supervision or placement on the secured dementia unit, but the facility did not have staff for one‑to‑one care. The former DON stated the resident was exit seeking and became more aggressive after the initial roof incident, and that the facility refused to take him back because he would not agree to placement on the secured dementia unit or to wearing an electronic wander guard bracelet. The hospital discharge summary documented that the resident was medically stable, did not meet criteria for inpatient psychiatric admission, and that his hospitalization was prolonged because his original facility declined his return, with eventual placement arranged at another facility with a secured dementia unit.
Inaccurate MDS Coding of PASRR Level II Status
Penalty
Summary
The deficiency involves the facility’s failure to accurately code the Minimum Data Set (MDS) assessment for a resident’s Preadmission Screening and Resident Review (PASRR) status. The resident was admitted with multiple psychiatric and cognitive diagnoses, including non-Alzheimer’s dementia, anxiety disorder, bipolar disorder, and psychotic disorder. A PASRR Level II Determination Notification letter dated 11/14/23 documented that the resident had a PASRR number ending in the letter H, indicating a halted PASRR Level II determination due to a primary diagnosis of dementia. Despite this, the resident’s most recent comprehensive significant change MDS assessment reported that the resident was not determined to have a PASRR Level II status. During an interview, the MDS nurse reviewed this assessment and confirmed it was incorrect and should have indicated a PASRR Level II status, and the DON stated she would expect residents’ MDS assessments to be accurate. This inaccurate coding of the PASRR Level II status on the MDS, despite existing documentation of the resident’s PASRR determination and diagnoses, constitutes the cited deficiency.
Failure to Request PASRR Level II Re-evaluation After Significant Change in Condition
Penalty
Summary
The deficiency involves the facility’s failure to request a Level II Preadmission Screening and Resident Review (PASRR) re-evaluation after a significant change in condition for a resident with a prior Level II PASRR determination. The resident was admitted with multiple psychiatric and cognitive diagnoses, including non-Alzheimer’s dementia, anxiety disorder, bipolar disorder, and psychotic disorder, and had a PASRR Level II Determination Notification dated 11/14/23, with a PASRR number ending in H indicating a halted Level II determination due to a primary dementia diagnosis. The resident’s electronic medical record showed a hospitalization and a subsequent significant change comprehensive MDS assessment, which documented that the resident was receiving hospice care. The Care Area Assessment for Cognitive Loss/Dementia also noted that the resident was now under hospice care. The facility’s current list of PASRR Level II residents identified this resident as having Level II status. During interviews, the MDS nurse acknowledged awareness that the resident was a Level II PASRR resident and stated that the resident should have been referred for a PASRR re-evaluation when the significant change MDS was completed, and that the resident had been on the original list of those needing a PASRR referral. However, the MDS nurse did not know whether Social Services had actually made the referral. The Director of Social Services reported that she did not submit a PASRR re-evaluation request for this resident following the significant change MDS, explaining that she believed a referral was unnecessary because the resident already had a Level II PASRR status. As a result, no PASRR Level II re-evaluation was requested despite the documented significant change in the resident’s physical and/or mental status and initiation of hospice care.
Failure to Complete Baseline Care Plan After Admission
Penalty
Summary
The facility failed to develop a baseline care plan within 48 hours of admission for a newly admitted resident. The resident, who had emphysema, a history of cerebral infarction, and repeated falls, was readmitted to the facility and had a Nursing re-admission Assessment Tool completed by a nurse. This assessment included information on mental and physical health, pain, Braden Scale, tuberculosis screening, fall risk/medication, smoking safety, device/air mattress safety, and elopement risk. However, review of the electronic medical record showed that no baseline care plan was completed following this admission. A comprehensive care plan was not initiated until several days after admission and, as of the survey review date, contained only one focus area related to nutritional status. During interviews, the DON stated that a baseline care plan was normally completed by the admitting nurse within 24 hours of admission and confirmed that none was present for this resident. The Unit Manager reported that the admitting nurse completed a re-admission assessment instead of the required admission assessment, and that the re-admission form did not include the baseline care plan component with focus areas, goals, and interventions. The admitting nurse stated she completed the forms that were auto-populated in the electronic system and did not know that the admission Nursing Collection Tool form was required to generate a baseline care plan.
Failure to Obtain and Enter Provider Diet Order for Readmitted Resident
Penalty
Summary
The deficiency involves the facility’s failure to obtain and enter a provider’s diet order into the electronic medical record (EMR) for a newly readmitted resident. The resident, who had emphysema, a history of cerebral infarction, repeated falls, cognitive impairment, confusion, and was oriented only to person, was discharged home and later hospitalized before being readmitted to the facility. Her hospital inpatient discharge summary specified a pureed diet with thin liquids. Upon readmission, a Nursing Re-admission Assessment Tool completed by a nurse documented her nutritional status, including that her usual food intake pattern was probably inadequate, that she had some or all natural teeth, and that she required partial to moderate assistance with eating. However, no provider diet order was entered into her EMR at the time of readmission. Surveyor observations on multiple occasions showed the resident receiving meals despite the absence of a provider diet order in the EMR. At breakfast, she was served a regular, pureed diet and consumed about 25% of the meal. At lunch, she was again served a regular diet with pureed foods and was observed feeding herself while seated in a reclining wheelchair. Review of the EMR confirmed there was no provider diet order in place. The Dietary Manager and Regional Dietary Manager verified that a diet order was missing and that a Communication Form from Nursing to Dietary, completed and signed by a Unit Manager, directed dietary staff to provide a regular diet with pureed textures and thin liquids based on the hospital discharge information. The Unit Manager acknowledged she had relied on the hospital discharge information and the Communication Form to Dietary, but confirmed that a provider’s diet order should have been entered into the EMR upon admission. The DON also stated that the diet order should have been entered into the EMR at admission and identified the lack of a provider diet order as a significant problem.
Failure to Keep Indwelling Catheter Drainage Bag Off the Floor
Penalty
Summary
The deficiency involves the facility’s failure to maintain a urinary catheter drainage bag off the floor for a resident with an indwelling urinary catheter. The resident had neuromuscular dysfunction of the bladder and a physician’s order for an indwelling catheter due to neurogenic bladder with urinary retention. The resident’s MDS documented severely impaired cognition and total dependence for most ADLs, and the care plan specified that the catheter tubing should be free of kinks or obstruction and the drainage bag kept in the proper location. During an observation, the resident was found in bed with the bed in a low position and the urinary catheter drainage bag lying flat on the floor. In a subsequent observation and interview, a nurse aide acknowledged that the catheter drainage bag was on the floor and stated she had been educated to hang the bag on the metal bed frame but reported it often fell off when the bed was in a low position. When the unit manager attempted to hang the bag on the bed frame, the drainage bag still touched the floor, and the manager stated the bed would need to be raised to prevent this and that the bag should never touch the ground due to possible contamination and germs. The ADON and DON both stated that it was never acceptable for a urinary catheter drainage bag to touch the ground and that staff had been educated on catheter care, confirming that the observed condition did not meet the facility’s expectations for catheter bag positioning.
Failure to Enter Physician Order for Oxygen Therapy
Penalty
Summary
The deficiency involves the facility’s failure to obtain and enter a physician’s order for oxygen therapy for a resident who was receiving supplemental oxygen. The resident was admitted with COPD, tobacco use, and anemia. On 12/15, the resident was observed asleep in bed on 3 L/min O2 via nasal cannula from a portable tank, without signs of discomfort or respiratory distress. A nurse progress note from earlier that afternoon documented that the nurse notified the provider of abnormal vital signs, including an O2 saturation of 64% on room air, and that the provider ordered oxygen at 2 L/min. The note further stated that the resident’s O2 saturation increased to 89% on 2 L/min, and oxygen was then increased to 3 L/min with saturation rising to 91%. Despite this, review of the electronic medical record that day showed no corresponding oxygen order entered. On the following day, the resident was again observed resting in bed on 3 L/min O2 via nasal cannula, alert and oriented to self and without signs of discomfort or difficulty breathing. A provider progress note documented upper respiratory infection symptoms with difficulty breathing and an O2 saturation of 90% while on 3 L/min O2. Review of the electronic medical record that afternoon again revealed no oxygen order. A subsequent provider note on 12/17 stated the resident had mild upper respiratory infection symptoms during the week, that O2 saturations had dipped below 90%, and that oxygen, antibiotics, and nebulizers were started with improvement in O2 saturation into the low 90s on room air. However, review of the chart at midday on 12/17 still showed no oxygen order. The unit manager, upon reviewing the record with the surveyor, confirmed that the nurse had documented receiving an oxygen order from the provider on 12/15 but had failed to create the required oxygen order in the electronic medical record by 12/17.
Medication Error Rate Above 5% Due to Omitted Inhaler Dose and Improper Insulin Pen Preparation
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with surveyors identifying 2 errors out of 26 opportunities (7.6%) during a medication administration observation. For one resident with an order for Breo Ellipta 200-25 mcg per actuation, to be given as one puff by mouth once daily at 8:00 AM for shortness of breath and wheezing related to COPD and/or asthma, the medication was not administered during the observed morning medication pass. The medication aide reported that the Breo Ellipta inhaler was not available on the medication cart, and the unit manager stated that the prior inhaler had been identified as expired and removed from the cart, and that a replacement had been ordered but not yet delivered. The DON stated she would have expected the inhaler to have been ordered before it was out or expired so it would have been available as scheduled. In a separate incident, surveyors observed a nurse preparing to administer Insulin Lispro via a prefilled insulin pen to another resident. The manufacturer’s Full Prescribing Information for the Insulin Lispro pen required priming with 2 units of insulin prior to each injection to ensure the pen was ready to dose and to remove air from the cartridge. The nurse attached a needle to the pen and dialed 15 units for administration but did not prime the pen before walking toward the resident’s room. When stopped outside the room and questioned, the nurse acknowledged she had not primed the pen and confirmed she was supposed to prime it before each injection. The DON confirmed that the Insulin Lispro pen needed to be primed with 2 units prior to each use and that she expected nursing staff to follow clinical guidelines for each medication administered.
Inaccurate Daily Nurse Staffing Postings Across Multiple Shifts
Penalty
Summary
The deficiency involves the facility’s failure to ensure that daily nurse staffing sheets accurately reflected the actual nursing staff who worked on 6 of 7 reviewed days. Surveyors compared the posted daily nurse staffing sheets with the internal nursing staff schedules and found multiple discrepancies. On one day, the schedule showed 5 LPNs and 11 CNAs on first shift and 1 LPN, 8 CNAs, and 3 CMAs on second shift, while the posted sheet showed only 4 LPNs and 9 CNAs on first shift and 2 LPNs, 9 CNAs, and 1 CMA on second shift. On another day, the schedule listed 4 LPNs on first shift, but the posted sheet showed only 3 LPNs. On a third day, the schedule showed 4 LPNs and 1 CMA on first shift, while the posted sheet showed 3 LPNs and 2 CMAs. Additional discrepancies included a day when the schedule showed 7 CNAs on third shift but the posted sheet showed 6 CNAs, another day when the schedule showed 5 LPNs on first shift but the posted sheet showed 4 LPNs, and a day when the schedule showed 1 RN on third shift but the posted sheet showed 3 RNs. Interviews with facility staff revealed confusion and inconsistent practices regarding responsibility for posting and updating the daily staffing sheets. The staff coordinator and two receptionists were identified as responsible for posting the sheets, typically in the morning for all three shifts, and for updating them to reflect callouts or schedule changes. The staff coordinator stated she worked weekdays and expected assigned nurses to make revisions after hours and on weekends, but she was not aware that the sheets had not been updated on the identified dates. One receptionist reported assisting with posting and stated that she, the staff coordinator, and nursing staff were responsible for revising the postings, but noted that nursing staff sometimes failed to communicate changes when staff called out. The other receptionist stated she never made revisions, had not been educated to do so, and had never been told it was her responsibility. The administrator stated that the staff coordinator was responsible for posting and updating the sheets and that he expected the sheets to be updated as needed to reflect the correct number and hours of nursing staff for each shift, and he assumed nursing staff made revisions when the staff coordinator was unavailable.
Failure to Administer Prescribed Pain Medication
Penalty
Summary
The facility failed to administer pain medication as ordered for a resident who was admitted with fractures to her left knee and right ankle. The resident had undergone surgical repair of the right ankle and was prescribed Oxycodone Hydrochloride for pain management. However, upon admission, the resident did not receive the prescribed narcotic pain medication due to the absence of a prescription from the hospital. Instead, the resident was given Acetaminophen, which did not adequately relieve her pain, as she rated her pain at an 8 or 9 on a scale of 1 to 10 until she received the ordered medication the following evening. Interviews with staff revealed that the Unit Manager was unable to obtain a prescription for the narcotic pain medication on the evening of the resident's admission. The Director of Nursing confirmed that the facility's on-call service would not provide a prescription for a narcotic without one from the hospital. The Pharmacy Consultant indicated that the ordered narcotic would have been beneficial for managing the resident's pain. The Administrator acknowledged that the nursing staff should have contacted the Physician or Nurse Practitioner to obtain the necessary prescription to ensure the resident's comfort.
Missed Urology Appointment for Catheter Change
Penalty
Summary
The facility failed to ensure that a resident was transported to a scheduled urologist appointment for a suprapubic indwelling urinary catheter change. The resident, who was severely cognitively impaired and required an indwelling urinary catheter, was scheduled for a catheter change at the urologist's office. However, there was no evidence in the medical record that the resident attended the appointment, and the appointment was not rescheduled. Interviews with the Appointment Coordinator and the Urology Clinic's Scheduler revealed discrepancies regarding the cancellation and rescheduling of the appointment. The Appointment Coordinator stated that the appointment was canceled, but the Urology Clinic's Scheduler confirmed that the appointment was not canceled and the resident was not brought to the appointment. The Director of Nursing acknowledged that the appointment was not placed on the transportation schedule and should have been rescheduled promptly. The resident was later admitted to the hospital with sepsis due to pneumonia and a urinary tract infection, and the suprapubic catheter was changed at the hospital. The Nurse Practitioner stated that the missed appointment did not cause the resident's decline or sepsis, attributing the decline to the resident's existing health conditions. The resident was eventually transferred to another facility for palliative care.
Failure to Administer Prescribed Pain Medication
Penalty
Summary
The facility failed to provide necessary pain medication to a resident who was admitted with fractures in both legs. The resident had a physician's order for Oxycodone Hydrochloride, a narcotic pain medication, which was not administered as prescribed on the evening of admission and the following morning. Instead, the resident received Acetaminophen, which did not adequately control her pain. The resident reported experiencing significant pain until the ordered medication was finally administered the next evening. The deficiency occurred because the facility did not obtain a prescription for the narcotic pain medication from the hospital or the on-call provider. The Unit Manager and Director of Nursing stated that the on-call provider would not issue a narcotic order without a prescription from the hospital. Consequently, the pharmacy could not release the medication from the electronic emergency back-up system. The facility's failure to secure the necessary prescription resulted in the resident experiencing unmanaged pain for an extended period.
Kitchen Deficiencies: Sink Leak and Improper Food Storage
Penalty
Summary
The facility was found to have several deficiencies in the kitchen area, including a malfunctioning sink drain and leaking pipe, which resulted in a large amount of standing water on the floor. This issue was observed during a survey, and it was noted that the problem had been ongoing for several weeks despite maintenance being notified multiple times. Additionally, the ceiling vents above the dry station and stove area were found to be dusty and dirty, which could potentially affect the food served to residents. Furthermore, four bags of cereal were observed to be unlabeled and improperly stored next to the tea and coffee station. Interviews with staff revealed that the maintenance department was responsible for cleaning the vents, but this had not been done in a while. The Dietary Aide mentioned that the cereal bags were usually used within a couple of days and were not stored properly. The Maintenance Director admitted to attempting to fix the sink issue previously but was unaware that it was still malfunctioning. The Administrator was not initially aware of the ongoing sink issue but acknowledged that a plumber had been contacted to address the problem.
Failure to Maintain Sanitary Conditions Around Trash Receptacles
Penalty
Summary
The facility failed to maintain sanitary conditions around the outdoor trash receptacle area, which was observed to have loose garbage and debris on multiple occasions. Observations on three consecutive days revealed masks, water bottles, debris, gloves, and bags of trash on the ground around the trash receptacles. Additionally, the staff break area, located near the trash receptacle area, was also observed to have food wrappers and drink bottles scattered on the ground. Interviews with facility staff, including two dietary aides, indicated that the issue of trash and debris around the receptacle area was ongoing. The dietary aides expressed uncertainty about who was responsible for keeping the area clean, despite their attempts to maintain it. A joint interview with the Administrator and Maintenance Director confirmed the ongoing issue, with the Administrator acknowledging a lack of clarity regarding responsibility for the area’s cleanliness. The Administrator expected housekeeping and kitchen staff to maintain the area free of trash and rodents.
Failure to Complete Quarterly Smoking Assessments
Penalty
Summary
The facility failed to complete quarterly smoking assessments for two residents, leading to a deficiency in ensuring a safe environment free from accident hazards. Resident #67, who was cognitively intact and had a history of heart failure and diabetes, was admitted to the facility and identified as a smoker. Despite being coded for smoking in the Minimum Data Set (MDS) and having a care plan that allowed unsupervised smoking, Resident #67 did not receive a quarterly smoking assessment from April 2023 until July 2024. The assessment completed in July 2024 confirmed the resident as an unsupervised smoker. Similarly, Resident #91, who was moderately cognitively impaired, was also identified as a smoker upon admission. The resident's care plan, revised in July 2024, permitted unsupervised smoking. However, like Resident #67, Resident #91 did not receive a quarterly smoking assessment from April 2023 until July 2024. Interviews with the Nurse Unit Manager and the Director of Nursing revealed that the responsibility for completing these assessments lay with the nursing staff, and both residents should have had their assessments completed quarterly. The Administrator was unaware of the missed assessments until the survey.
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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