Sapphire Ridge Health And Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Brevard, North Carolina.
- Location
- 115 N Country Club Road, Brevard, North Carolina 28712
- CMS Provider Number
- 345208
- Inspections on file
- 25
- Latest survey
- May 7, 2026
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Sapphire Ridge Health And Rehabilitation during CMS and state inspections, most recent first.
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 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 serve the correct portion size of beef hamburger steak to residents on a mechanically altered diet, providing only 2 ounces instead of the planned 4 ounces. This error occurred due to the use of an incorrect ladle by dietary staff, affecting 18 residents.
The facility failed to manage food storage and labeling, resulting in expired and potentially spoiled food items being available for use. Expired items were found in the kitchen's walk-in refrigerator and dry goods storage, while an open container of nectar-thick milk in the memory care unit's nutrition refrigerator lacked a proper opening date. The Dietary Manager and Nurse #1 were unaware of the proper procedures, leading to these deficiencies.
The facility failed to document vaccine consents or declinations in the medical records of five residents and did not assess vaccine eligibility for two residents. The DON was unaware of the need to include these documents in medical records, while the Administrator expected them to be included. Additionally, consent forms for two residents were incomplete, lacking answers to questions about vaccine safety and appropriateness.
The facility failed to document COVID-19 vaccination status for five residents, including acceptance or refusal, and did not assess vaccine eligibility for a resident. Consent and declination forms were missing from medical records, and a consent form was incomplete. The DON was unaware of the need to include these forms in records, while the Administrator expected them to be complete and included.
The facility failed to serve lunch meals on time in the main dining room on two consecutive days, affecting residents with severe cognitive impairments. Observations and interviews revealed that late meal service was a regular issue, attributed to a shortage of dinnerware and process inefficiencies. The administrator acknowledged the problem but did not provide a clear resolution.
A resident with cognitive impairment and specific medical conditions did not receive the twice-weekly showers they preferred due to an oversight in the shower assignment process. The Unit Manager confirmed the omission of the resident's room number from the assignment, resulting in the resident receiving only one shower since admission. The Administrator expected resident preferences to be honored.
The facility failed to communicate resolutions to concerns raised during Resident Council meetings, particularly regarding dietary and laundry issues. Residents felt their concerns were not adequately addressed or communicated back to them. The Activities Director acknowledged the oversight, and the Administrator was unaware of the residents' dissatisfaction with the communication process.
A cognitively intact resident with non-Alzheimer's dementia filed grievances regarding care concerns, including call light response time and incontinence care. The facility's grievance policy required written resolutions, but the Grievance Officer only provided verbal resolutions, and the grievance forms lacked detailed information and resident signatures. The resident expressed a desire for written resolutions, and the Administrator acknowledged the need for more detailed documentation.
A facility failed to thoroughly investigate an alleged abuse incident involving a resident with non-Alzheimer's dementia. The resident reported being pushed onto the bed by a nurse aide, but the investigation lacked a statement from the resident and comprehensive interviews. The facility concluded the resident was self-transferring and falling, but the abuse allegation was not substantiated.
The facility inaccurately coded MDS assessments for three residents, leading to errors in documenting restraints, dental issues, and falls. One resident was incorrectly noted to use bed rails as a restraint, another's dental problems were not reflected in the MDS, and a fall was omitted from a discharge assessment. These errors were acknowledged by the MDS Coordinator, with expectations from the DON and Administrator for accurate coding.
A resident with severe cognitive impairment and physical limitations experienced a delay in receiving assistance with lunch, waiting approximately one hour past the scheduled meal time. The resident, who required substantial assistance, watched others eat while waiting, leading to a compromised dignified dining experience. The facility's administrator recognized the issue as a dignity concern, suggesting it might be a process issue.
A resident with a history of a femur fracture and epilepsy did not receive adequate assistance with personal hygiene, including nail care and shaving, despite being dependent on staff for these activities. Scheduled showers were missed, and the resident was found with long fingernails and chin hairs, which she was unable to manage herself. Staff interviews confirmed that these tasks were supposed to be done during bath days, but this was not consistently provided.
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 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.
Incorrect Portion Size Served to Residents on Mechanically Altered Diet
Penalty
Summary
The facility failed to provide the correct portion size of beef hamburger steak for residents receiving a mechanically altered diet. During the lunch meal tray preparation, it was observed that residents on a mechanically altered diet received only a 2-ounce portion of beef hamburger steak instead of the planned 4-ounce portion. This discrepancy was due to the use of an incorrect ladle with a red handle, which was intended for a 2-ounce portion, rather than the correct utensil for a 4-ounce portion. The Dietary Manager and another staff member used this incorrect ladle, resulting in residents receiving half the intended portion size. The facility's diet consistency census report indicated that 18 out of 97 residents were on a mechanically altered diet. The planned menu for the day specified a 4-ounce beef hamburger steak for each resident. However, the Dietary Manager confirmed that the incorrect portion size was served due to an oversight in utensil selection. The guide used by staff to determine portion sizes did not include ladles, which contributed to the error. The Administrator expressed an expectation that residents on a mechanically altered diet should receive the correct portion size and that the appropriate utensils should be used to ensure accuracy.
Deficient Food Storage and Labeling Practices
Penalty
Summary
The facility failed to properly manage food storage and labeling, leading to the availability of expired and potentially spoiled food items in the kitchen and nutrition refrigerator. During an initial tour of the kitchen, it was observed that several food items, including enchilada sauce, sliced lemons, and a container of sliced bananas mixed with pineapple tidbits, were stored in the walk-in refrigerator despite being past their expiration dates or showing signs of spoilage. Additionally, expired nutritional drink supplements and thickened lemon-flavored water were found in the dry goods storage area. The Dietary Manager admitted to not checking the walk-in refrigerator for expired or spoiled food on the day of the inspection and acknowledged that expired items in the dry goods storage area were overlooked. In a separate incident, an open container of nectar-thick milk was found in the nutrition refrigerator on the memory care unit without a date indicating when it was opened. Nurse #1, who was present during the observation, was unaware of when the container was first opened and mistakenly believed it could be used for seven days, despite the label indicating it should be discarded four days after opening. The Administrator confirmed the expectation that food items should be discarded based on expiration or use-by dates and not left available for use.
Deficiency in Vaccine Documentation and Assessment
Penalty
Summary
The facility failed to document the acceptance or refusal of influenza and pneumonia vaccinations in the medical records of five residents. For Resident #20, despite multiple attempts to contact the Power of Attorney, the Vaccine Declination Form was not included in the medical record. Resident #44's consent forms for both influenza and pneumonia vaccines were missing from the medical record, even though verbal and email consents were obtained. Similarly, Resident #37's declination and consent forms were not documented in the medical record, despite the resident consenting to and receiving the influenza vaccine. Resident #80's medical record lacked documentation of a declination form for the pneumonia vaccine, and the influenza vaccine declination form was not included. Resident #62's medical record did not contain any documentation of acceptance or declination of the vaccines, although the resident was offered and declined both. The Director of Nursing was unaware that these documents needed to be part of the medical record, while the Administrator expected them to be included. Additionally, the facility failed to assess the eligibility for vaccination for Residents #44 and #37. The Vaccine Consent Forms for these residents were incomplete, with unanswered questions regarding the safety and appropriateness of the vaccines. The Director of Nursing stated that the staff responsible for obtaining consent should have ensured these questions were answered, while the Administrator expected all required information to be complete.
Deficiency in COVID-19 Vaccination Documentation and Assessment
Penalty
Summary
The facility failed to properly document the COVID-19 vaccination status of five residents, including their acceptance or refusal of the vaccine. For Resident #20, attempts to contact the Power of Attorney for vaccine declination were unsuccessful, and the declination form was not included in the medical record. Resident #44 received verbal consent from a guardian for vaccination, but the consent form was missing from the medical record. Resident #37 declined the vaccine, but the declination form was not documented in the medical record. Resident #80's family member verbally declined the vaccine, yet the declination form was not included in the medical record. Resident #62's medical record lacked any documentation of vaccine acceptance or declination. The Director of Nursing (DON) was unaware that these forms needed to be part of the medical record, while the Administrator expected them to be included. Additionally, the facility failed to assess the eligibility of Resident #44 for the COVID-19 vaccine. The Vaccine Consent Form for Resident #44, who was severely cognitively impaired, was incomplete, with all questions regarding vaccine appropriateness left unanswered. The DON stated that the staff responsible for obtaining consent should have ensured the questions were completed. The Administrator expected all required information on vaccine consents to be filled out, with no questions left blank. The vaccine was administered by an outside company, but the facility staff were responsible for obtaining and completing the consent forms.
Late Meal Service in Dining Room
Penalty
Summary
The facility failed to serve lunch meals at the scheduled time in the main dining room on two consecutive days, leading to a deficiency in meal service. On both days, residents were observed waiting for their meals beyond the posted lunch time of 12:30 PM. Specifically, on the first day, two residents with severe cognitive impairments and dietary needs were not served their meals until 1:20 PM, despite being seated in the dining room. This delay was confirmed by the facility's administrator, who acknowledged the issue but could not provide an explanation for the late service. Interviews with residents, family members, and staff revealed that late meal service was a regular occurrence. A resident council group expressed that meals were consistently served late, whether in the dining room or in residents' rooms. The dietary manager identified several contributing factors to the delays, including a shortage of dinnerware and the need for staff to collect and return meal trays promptly. The dietary manager also noted that if a resident's meal tray was not delivered to the correct location, it required additional time to rectify, further delaying meal service. The administrator was aware of the ongoing issue and confirmed that residents had raised concerns about late meals. She noted that the shortage of dinnerware contributed to the delays and that staff were instructed not to rush residents through their meals. The administrator suggested that the problem might be related to process issues rather than staffing shortages. Despite these acknowledgments, the facility did not provide a clear resolution to the problem, resulting in continued late meal service for residents.
Failure to Honor Resident's Shower Preferences
Penalty
Summary
The facility failed to honor a resident's preference for twice-weekly showers, as evidenced by observations, record reviews, and interviews with the resident and staff. The resident, who was admitted with diagnoses including metabolic encephalopathy and heart failure, had a moderately impaired cognition and required assistance with activities of daily living. Despite being scheduled for showers on Tuesdays and Fridays, there was no documentation to indicate that the resident received a shower or bed bath on the specified dates. The resident reported not having received a shower since admission, except for one documented instance. The Unit Manager confirmed that the resident's room number was omitted from the shower assignment, leading to the oversight. The shower sheets, which were supposed to be documented by nurse aides, were not available for the dates in question. The Unit Manager acknowledged the error and confirmed that the resident's preference for showers twice a week was not honored. The Administrator also stated that the expectation was for resident bathing preferences to be respected.
Failure to Communicate Resolutions to Resident Council Concerns
Penalty
Summary
The facility failed to effectively communicate resolutions to concerns raised during Resident Council meetings, as evidenced by the review of meeting minutes and interviews with residents and staff. During a Resident Council meeting, residents expressed preferences for specific beverages and concerns about laundry issues, which were noted as resolved but still under monitoring. However, the grievance form lacked details on the investigation and resolution process, and there was no staff member assigned to investigate the laundry concern. Furthermore, the subsequent Resident Council meeting minutes did not reflect any communication of the facility's efforts to address the previously voiced concerns. Interviews with residents revealed a perception that their concerns, particularly regarding laundry and dietary issues, were not adequately addressed or communicated back to them. The Activities Director, who had recently started facilitating the meetings, acknowledged the oversight in not following up with the Resident Council on group concerns. The Administrator was aware of the issue with late meals but was unaware that residents felt their concerns were not being communicated back to them. The Social Worker confirmed that the staff member facilitating the meetings was responsible for communicating resolutions to the Resident Council.
Failure to Implement Grievance Policy
Penalty
Summary
The facility failed to implement its grievance policy for a resident who was cognitively intact and had non-Alzheimer's dementia. The resident filed two grievances regarding care concerns, including issues with receiving water, call light response time, and the length of time it took to receive incontinence care. The facility's grievance policy required written resolutions to be provided to residents, but the Grievance Officer only verbally communicated the resolutions to the resident. The grievance forms lacked detailed information about the grievances and were not signed by the resident. The Social Worker, who served as the Grievance Officer, confirmed that he did not provide written resolutions to grievances, and the resident expressed a desire to receive written resolutions to understand what actions were taken. The Administrator acknowledged that the grievance forms could contain more information about the grievances and their resolutions. This failure to provide written resolutions and adequately document grievances led to the deficiency identified by the surveyors.
Incomplete Investigation of Alleged Abuse Incident
Penalty
Summary
The facility failed to conduct a thorough investigation of an alleged staff-to-resident abuse incident involving Resident #8. The resident, who was cognitively intact and diagnosed with non-Alzheimer's dementia, reported that on the night of the incident, a nurse aide pushed her head onto the bed. The facility initiated an investigation, suspended the nurse aide, and notified relevant parties, including the physician, responsible party, Adult Protective Services, and local police. However, the investigation lacked a statement from Resident #8 and did not include interviews with other potential witnesses or involved parties. The Director of Nursing and the Administrator were unable to recall how they became aware of the allegation and could not explain why the investigation did not include a statement from the resident. The investigation concluded that the resident attempted to self-transfer and was falling when the nurse aide intervened, but it did not substantiate the abuse allegation. The facility's failure to include a statement from the resident and conduct comprehensive interviews resulted in an incomplete investigation, contrary to their policy on handling abuse allegations.
Inaccurate MDS Coding for Restraints, Dental Issues, and Falls
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) assessments for three residents, leading to discrepancies in the documentation of restraints, dental issues, and falls. For one resident, the quarterly MDS assessment incorrectly indicated the use of bed rails as a restraint, despite observations showing no bed rails on the bed. This error was attributed to the assessment being coded by an employee not present in the building. Another resident's significant change MDS assessment failed to reflect severe dental issues, despite a dentist's note and observations confirming multiple broken teeth. The MDS Coordinator acknowledged the oversight, noting that another staff member had coded the dental section. Additionally, a resident's discharge MDS assessment did not document a fall that occurred during a transfer, as noted in a nurse's progress note. The MDS Coordinator admitted to not coding the fall, and both the Director of Nursing and the Administrator expected the MDS assessments to accurately reflect the residents' conditions. These inaccuracies in MDS coding highlight a failure in ensuring that resident assessments are precise and reflective of their actual conditions.
Resident's Dignity Compromised Due to Delayed Meal Service
Penalty
Summary
The facility failed to provide a dignified dining experience for a resident with severe cognitive impairment and physical limitations, who required substantial assistance with eating. The resident, diagnosed with hemiplegia, hemiparesis, and vascular dementia, was observed sitting in the main dining room for approximately one hour past the scheduled meal time without being served or assisted with his lunch. During this time, the resident watched other residents receive and eat their meals, which could lead to feelings of being forgotten or frustrated. The deficiency was observed during a continuous observation of the lunch meal, where the resident was seated at a table in the back of the dining room. Despite being alert and expressing hunger, the resident was not served until 1:25 PM, well after the scheduled 12:30 PM meal time. The delay was attributed to the process of serving residents who could eat independently first, followed by those requiring assistance. The facility's administrator acknowledged the issue, noting it as a dignity concern and suggesting it might be a process issue rather than a staffing problem.
Failure to Assist Resident with Personal Hygiene
Penalty
Summary
The facility failed to provide necessary assistance with personal hygiene for a resident who was dependent on staff for activities of daily living. The resident, who had a history of a right femur fracture, presence of an artificial hip joint, and epilepsy, required substantial to maximal assistance for personal hygiene tasks such as showering and bathing. Despite being scheduled for showers twice a week, records indicated that the resident only received two showers and several bed baths over a period of time, with no documentation for certain scheduled shower days. During an observation, the resident was found with long fingernails and overgrown chin hairs, which she expressed a desire to have trimmed but had not been offered assistance by the staff. Interviews with staff revealed that nail trimming and shaving were supposed to be done during bath days, but this was not consistently provided. The resident was unable to trim her own nails due to their hardness and was not aware of the chin hairs until pointed out. The Unit Manager confirmed the resident's need for assistance and reassured her that care would be provided. The facility's Administrator acknowledged the expectation for staff to offer assistance with personal hygiene during bathing routines, which was not adequately met in this case.
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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