Senior Citizens Home
Inspection history, citations, penalties and survey trends for this long-term care facility in Henderson, North Carolina.
- Location
- 2275 Ruin Creek Road, Henderson, North Carolina 27537
- CMS Provider Number
- 345316
- Inspections on file
- 20
- Latest survey
- March 12, 2026
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Senior Citizens Home during CMS and state inspections, most recent first.
The facility failed to maintain clean HVAC vents in the kitchen, where two of three vents located above a food preparation table holding wrapped silverware were observed with dark debris on the metal surfaces. On a follow-up observation, the vents remained in the same condition while the air system was operating and blowing toward the tray line. The CFM reported that HVAC filters were not on the kitchen cleaning schedule and that Maintenance handled vent cleaning every one to two months but could not specify when it was last done. The Maintenance Director stated that a change in company ownership resulted in the removal of automated reminders from the work order software, and he believed the corroded filters were original and could not recall the last cleaning.
A resident with COPD, depression, and bipolar disorder did not receive multiple doses of newly ordered Divalproex, Olanzapine, and Trelegy Ellipta after admission because the medications were never obtained from the pharmacy. Over several days, nurses documented on the MAR that these medications were not administered and repeatedly noted they were "on order," with one nurse acknowledging she did not check the Pyxis and did not contact the family for a home supply. Staff believed administrative nurses had ordered the medications and that orders would transmit electronically to the new pharmacy as with the prior system, but the pharmacy later confirmed it did not receive faxed orders for these drugs until several days after they were written, during which time the resident went without the prescribed anticonvulsant, antipsychotic, and triple-therapy bronchodilator.
A resident with COPD and bipolar disorder did not receive newly ordered Divalproex, Olanzapine, and Trelegy Ellipta for several days because the medications were not available and remained "on order" from the pharmacy. Multiple nurses documented on the MAR that these medications were not administered on several consecutive days, citing that they were on order. The resident reported lacking his inhaler and some other medications for the first few days after admission. A nurse practitioner documented that the resident had missed doses of Trelegy, Valproic Acid, and Olanzapine and stated that interruption of these medications could cause mood instability, increased behaviors, and breathing issues, and that the medications should have been administered as ordered.
The facility's assessment lacked input from direct care staff and residents, and failed to evaluate contracted services for essential care. The staffing plan did not address specific shift needs or changes in resident population, potentially affecting all 49 residents.
The facility failed to submit accurate PBJ data to CMS for Q3 2024, missing RN hours and 24-hour licensed nursing coverage on specific dates. The Human Resources Manager submitted incomplete data due to delays in receiving agency staff information, assuming corrections would be made later. The Administrator confirmed the presence of required staff, indicating a reporting error.
The facility failed to conduct quarterly reviews of care plans for five residents, resulting in outdated care plans. Residents with conditions such as COPD, diabetes, and dementia had their last reviews in mid-2024, with no updates since. The DON, also serving as the MDS Nurse, acknowledged the backlog, while the Administrator was initially unaware of the issue.
The facility inaccurately coded MDS assessments for two residents, leading to deficiencies in falls and restraints. One resident's fall with a major injury was not recorded, while another resident's bed rails, used for mobility, were incorrectly coded as restraints. These errors were acknowledged by the MDS Nurse and DON.
A facility failed to document a physician order for dialysis for a resident with end-stage renal disease. The resident was admitted with a hospital discharge summary that included dialysis instructions, but the Unit Manager omitted entering the order in the medical record. Interviews revealed that staff were aware of the resident's dialysis needs, but the order was not transcribed, as confirmed by the DON and Administrator.
The facility failed to post accurate nurse staffing data for 18 days, with discrepancies between the Daily Nursing Staffing Forms and actual staffing levels. The Scheduler admitted to errors, and the new DON was unaware of the inaccuracies, highlighting a lack of oversight in the staffing data process.
Unsanitary Kitchen HVAC Vents Above Food Preparation Area
Penalty
Summary
The facility failed to maintain kitchen HVAC equipment in a clean and sanitary condition, resulting in two of three HVAC vents located approximately two feet above a food preparation table, where wrapped silverware was stacked for lunch service, being observed with dark debris on the metal vents. During an initial kitchen tour with the Certified Food Manager, the air filter system was off, yet the debris was visible on the vents above the prep table. A subsequent observation the following day found the kitchen filters in the same condition, with dark debris still present on the vents while the air filter system was on and blowing air toward the tray line located about six feet away, although the tray line was not in use at that time. In interviews, the Certified Food Manager stated that the HVAC filters were not included on the kitchen cleaning schedule and that Maintenance came in every one to two months to clean the vents, but she was unsure when the filters had last been cleaned. The Maintenance Director reported that after a recent change in company ownership, the automated reminder to clean the kitchen vents was no longer appearing in the facility’s work order software, and he believed the filters appeared original with corrosion and could not recall when he last cleaned the vents. The Administrator acknowledged the condition of the HVAC filters during interview.
Failure to Obtain and Administer Ordered Psychotropic and COPD Medications After Pharmacy Transition
Penalty
Summary
The deficiency involves the facility’s failure to ensure the acquiring, dispensing, and administration of ordered medications for one resident, resulting in multiple missed doses of an anticonvulsant, an antipsychotic, and a COPD maintenance inhaler. The resident was admitted with diagnoses including COPD, depression, and bipolar disorder and had new physician orders initiated for Divalproex Sodium 1000 mg at bedtime for bipolar disorder, Olanzapine 2.5 mg at bedtime for bipolar disorder, and Trelegy Ellipta one puff daily for COPD. Medication Administration Records (MARs) for several days showed these medications were not administered, with chart codes referencing progress notes that documented the medications were still on order rather than available for use. For Divalproex Sodium, the MAR documented that the medication was not given on two separate days, and nursing notes on those days stated the medication was on order. For Olanzapine, the MAR showed it was not administered on three days, with corresponding notes from two different nurses indicating the medication was on order each time. For Trelegy Ellipta, the MAR documented it was not administered over four consecutive days, with multiple nursing notes stating the inhaler was on order and one health status note indicating the on-call provider was notified that the facility was still awaiting delivery of the medication. On one of the days Trelegy was not administered, there was no corresponding medication administration note in the electronic record. Interviews revealed that nursing staff were aware that the resident had not received all ordered medications after admission and believed medications had been ordered by administrative nurses and were pending delivery from the pharmacy. One nurse acknowledged not checking the Pyxis for availability of medications and did not contact the resident’s family to see if there was a home supply. The DON stated the facility had recently switched to a new pharmacy and believed orders would transmit electronically as with the prior system, and that the facility was not aware the resident’s medication orders had not been transmitted. Pharmacy staff reported that the orders for the resident’s Divalproex, Olanzapine, and Trelegy were not actually received until several days after the orders were written, at which time the medications were delivered, confirming that the medications had not been available during the period they were documented as “on order.”
Missed Psychotropic and COPD Medications Due to Pharmacy Ordering Failure
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors when multiple newly ordered medications were not administered over several days because they were not available from the pharmacy. The resident was admitted with COPD, depression, and bipolar disorder and had new physician orders initiated for Divalproex Sodium 1000 mg at bedtime for bipolar disorder, Olanzapine 2.5 mg at bedtime for bipolar disorder, and Trelegy Ellipta one puff daily for COPD. Medication Administration Records (MARs) for several days in February showed these medications were not given, with chart codes referencing progress notes that documented the medications were “on order.” For Divalproex Sodium, the February MAR showed missed doses on two separate days by the same nurse, who documented in medication administration notes that the medication was on order and therefore not administered. For Olanzapine, the MAR showed missed doses on three consecutive days by two different nurses, each documenting in medication administration notes that the medication was on order and not available to administer. For Trelegy Ellipta, the MAR showed missed doses on four consecutive days by three different nurses, with notes on three of those days stating the medication was on order; there was no corresponding medication administration note for one of the missed days. Nursing documentation also showed the resident was on 2 L/min oxygen via nasal cannula with even, unlabored respirations during this period. Interviews confirmed that nursing staff did not administer the Divalproex Sodium, Olanzapine, and Trelegy Ellipta because the medications had not arrived from the pharmacy and were considered to be on order. The resident reported that he did not have his inhaler and a couple of other medications when he first arrived and that it took a few days before he received all of his medications. A nurse practitioner progress note documented that the resident was seen for a follow-up visit related to missing medications and that he had missed doses of Trelegy, Valproic Acid, and Olanzapine after admission. The nurse practitioner stated that interruption of Depakote and Olanzapine could cause mood instability and increased behaviors, and omission of Trelegy could cause increased breathing issues, and that the medications should have been administered as ordered.
Deficiency in Facility Assessment and Staffing Plan
Penalty
Summary
The facility failed to ensure the involvement of required parties in developing the Facility Assessment, which is crucial for determining necessary resources for resident care during both regular operations and emergencies. The assessment was revised and updated multiple times, but it lacked input from direct care staff, residents, resident representatives, and family members. This oversight in collaboration could potentially affect the quality of care provided to all 49 residents in the facility. Additionally, the Facility Assessment did not evaluate contracted services for medical supplies, ambulance, emergency services, and dialysis, which are essential for resident care. The staffing plan outlined the desired number of FTEs for nurses and CNAs but failed to address specific staffing needs for each shift, weekends, or changes in the resident population. The Administrator, who was not present during the implementation of the new process, did not update or review the assessment, indicating a lack of oversight and comprehensive planning.
Inaccurate PBJ Data Submission Due to Incomplete Payroll Information
Penalty
Summary
The facility failed to submit accurate payroll data on the Payroll Based Journal (PBJ) report to the Centers for Medicare and Medicaid Services (CMS) for the third quarter of the fiscal year 2024. Specifically, the PBJ report lacked Registered Nurse (RN) hours for certain dates and did not reflect 24-hour licensed nursing coverage on other specified dates. Upon review, it was found that the facility did have RN hours and 24-hour licensed nursing coverage for those dates, as evidenced by the Posted Daily Nursing Staffing Forms, Daily Staffing Sheet, and nursing staff time detail reports. The Human Resources Manager, responsible for entering nursing hours into the payroll system, admitted to submitting incomplete data to the corporate office due to delays in receiving information from agency staff. She updated the payroll system once the information was received, assuming the PBJ reports would be corrected and resubmitted. The Administrator confirmed that the PBJ data was submitted based on the information entered by the Human Resources Manager and acknowledged the presence of RN hours and licensed nursing staff as required, suggesting an error occurred during data reporting.
Failure to Conduct Timely Care Plan Reviews
Penalty
Summary
The facility failed to conduct quarterly reviews of resident care plans for five residents, leading to deficiencies in maintaining up-to-date care plans. Resident #23, who was admitted with chronic obstructive pulmonary disease and osteoarthritis, had their last care plan review on 7/30/24, with no subsequent updates. Similarly, Resident #6, diagnosed with diabetes, chronic kidney disease, and stroke, had their care plan last reviewed on 5/23/24. Both residents were found to be cognitively intact during their Minimum Data Set (MDS) assessments. The Director of Nursing (DON), who also served as the MDS Nurse, acknowledged the overdue reviews and was aware of the backlog in care plan updates. Additional residents, including Resident #9 with heart disease and atrial fibrillation, Resident #8 with dementia and atrial fibrillation, and Resident #45 with diabetes and a history of stroke, also had outdated care plans. The last reviews for these residents were conducted in July 2024, with no further updates. Resident #8 and Resident #45 were noted to be severely cognitively impaired. Interviews with the DON confirmed the overdue status of these care plans, and the facility's Administrator expressed an expectation for timely reviews and updates, although she was initially unaware of the issue.
Inaccurate MDS Coding for Falls and Restraints
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) assessments for two residents, leading to deficiencies in the areas of falls and restraints. Resident #45, who was admitted with osteoarthritis, dementia, and a history of stroke, experienced a fall resulting in a major injury. However, the MDS assessment inaccurately indicated that there were no falls since admission. This error was acknowledged by the MDS Nurse and the Director of Nursing (DON), who confirmed that the assessment should have been coded for one fall with a major injury. Resident #23, who was cognitively intact, had an active physician order for 1/4 bed rails to assist with bed mobility. The MDS assessment incorrectly coded these side rails as physical restraints used daily. Observations and interviews confirmed that the side rails were used by the resident for mobility and should not have been coded as restraints. The MDS Nurse and the DON both recognized the coding error, indicating a failure to ensure accurate resident assessments.
Failure to Document Physician Order for Dialysis
Penalty
Summary
The facility failed to have a physician order for dialysis in the medical record for a resident who required such services. The resident, diagnosed with end-stage renal disease stage 5, was admitted to the facility with a hospital discharge summary that included dialysis instructions. However, the Unit Manager, responsible for admitting the resident, omitted entering the physician order for dialysis in the medical record. During interviews, both the Unit Manager and a nurse acknowledged the absence of the order, despite being aware that the resident received dialysis. The Director of Nursing confirmed that it was the admission nurse's responsibility to ensure physician orders were entered, and the Administrator reiterated that nursing staff should have transcribed the orders from the hospital discharge summary.
Inaccurate Nurse Staffing Data Posting
Penalty
Summary
The facility failed to post accurate licensed nurse staffing data for 18 out of 30 days reviewed. The discrepancies were found in the Daily Nursing Staffing Forms for various shifts throughout the month. For the 7:00 am-3:00 pm shift, there were multiple instances where the number of Licensed Practical Nurses (LPNs) and Registered Nurses (RNs) recorded on the Daily Nursing Staffing Form did not match the actual staffing numbers on the Daily Staffing Sheet. Similar inaccuracies were noted for the 3:00 pm-11:00 pm and 11:00 pm-7:00 am shifts, where the recorded staffing levels often showed fewer RNs and LPNs than were actually present according to the Daily Staffing Sheet. Interviews with facility staff revealed that the Scheduler used a staffing template to complete the Daily Staffing Form and admitted to missing the days where the staffing was recorded incorrectly. The Director of Nursing (DON), who was new to the facility, was unaware of the inaccuracies in the Daily Staffing Forms and had not previously checked them for accuracy. The DON stated that the Scheduler should verify the information before posting it, indicating a lack of oversight and verification in the staffing data recording process.
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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