Signature Healthcare Of Kinston
Inspection history, citations, penalties and survey trends for this long-term care facility in Kinston, North Carolina.
- Location
- 907 Cunningham Road, Kinston, North Carolina 28501
- CMS Provider Number
- 345365
- Inspections on file
- 23
- Latest survey
- December 9, 2025
- Citations (last 12 mo.)
- 8
Citation history
Health deficiencies cited at Signature Healthcare Of Kinston during CMS and state inspections, most recent first.
Lunch was served approximately two hours late to all dining areas after kitchen staffing shortages led to unwashed dishes from the previous dinner service, which delayed both breakfast and lunch meal times. The interim dietary manager confirmed the delays were due to staff quitting without notice, and the administrator was aware of prior late meal services but had not previously identified staffing as the cause.
A resident admitted with multiple serious mental health diagnoses, including bipolar disorder, PTSD, depression, and anxiety, did not receive a required Level II PASRR evaluation despite ongoing psychiatric symptoms and medication changes. The facility relied on a prior Level I screening and did not reassess the need for a Level II evaluation, as confirmed by staff interviews and record review.
A resident with a tracheostomy did not have an Ambu bag at the bedside as required by policy and physician orders, and nursing staff were unable to immediately locate the Ambu bag on the crash cart. Additionally, a nurse performed tracheostomy care without maintaining sterile technique after contaminating her gloves, and staff training and competency checks were found to be insufficient.
A resident with dysphagia and physician orders for a pureed diet did not receive the required pureed bread item as specified on the dietitian-approved menu. Staff confirmed the omission during meal service, and the issue was only addressed after surveyor intervention.
A resident who was cognitively intact and independently mobile in a wheelchair was verbally abused and threatened by a housekeeper, who used profane and racially charged language and physically pushed her cart into the resident's wheelchair. Multiple staff witnessed the incident, intervened to separate the individuals, and confirmed the abusive behavior, which was substantiated by the facility's investigation.
Two residents experienced misappropriation and exploitation when staff solicited and used their funds for personal gain. One resident with dementia lost over $2,200 after giving her debit card to a nurse aide, who made unauthorized purchases. Another cognitively intact resident gave $65 to a nurse aide who requested money for her children and was not reimbursed. Both incidents were substantiated, and the staff involved were terminated.
The facility did not notify Adult Protective Services (APS) of substantiated cases of misappropriation of property and verbal abuse involving three residents, despite facility policy requiring such reporting. Incidents included a resident's debit card being misused by a nurse aide, another resident being verbally abused and physically threatened by a housekeeper, and a third resident reporting a missing valuable ring. Documentation and staff interviews confirmed APS was not notified in these cases.
A resident's MDS assessment was inaccurately coded when a physician-documented contraindication to gradual dose reduction (GDR) of a psychotropic medication was not properly recorded. The MDS nurse acknowledged the error during an interview, confirming that the section should have indicated the GDR was clinically contraindicated as documented by the physician.
The facility failed to accurately code MDS assessments for several residents, including a resident with diabetes not coded for hypoglycemic medications, a smoker not coded for tobacco use, a resident with a colostomy not coded for an ostomy, and a resident with dementia not coded for a gradual dose reduction of antipsychotic medication. These errors were acknowledged by the MDS Nurse and confirmed by the Interim Director of Nursing and the Administrator.
A resident was left with medications on her overbed table without an assessment for self-administration. The resident, who was cognitively intact, had Acetaminophen and Ciprofloxacin left in medication cups to take at her discretion. Nurse #1 admitted to leaving the medications unsupervised, and both the Assistant Director of Nursing and the Interim Director of Nursing confirmed the lack of assessment and supervision.
A facility failed to provide the required CMS Notice of Medicare Non-Coverage (NOMNC) and Skilled Nursing Facility Advanced Beneficiary Notice (ABN) for a resident with moderate cognitive impairment. The resident's Medicare Part A skilled services ended, but the benefit was not exhausted, and there was no evidence that the necessary notices were given. The Business Office Manager indicated that the former Receptionist was responsible for the forms, but they were not completed or uploaded.
A facility failed to refer a resident with a new PTSD diagnosis for a PASARR evaluation. The resident, initially admitted with adjustment disorder, was not screened for PASARR despite a new PTSD diagnosis. The Social Worker did not make the referral, believing the resident was doing well and unaware of her nightmares. The Administrator confirmed that a new psychiatric diagnosis should have prompted a referral.
A facility failed to document the administration of Acetaminophen for a resident with peripheral vascular disease. A nurse administered 650 mg of Acetaminophen, but this was not recorded in the resident's MAR. The nurse believed he had documented it, and the Interim DON confirmed it should have been documented.
A resident's room in the facility was found to have a scuffed bathroom door with peeling paint and a buildup of black debris on the grout at the base of the doorway. Despite the resident's complaints to staff, no maintenance work order was found, and staff interviews revealed a lack of awareness of the issues. The facility's maintenance and housekeeping procedures failed to address the resident's concerns.
Delayed Meal Service Due to Staffing and Dishwashing Issues
Penalty
Summary
The facility failed to serve lunch at the scheduled times for all dining areas on 12/01/25, with meals being delivered approximately two hours later than the posted mealtimes. The posted schedule indicated lunch service was to begin at 12:00 PM in the dining room and continue in staggered intervals across the 500, 400, 300, 200, and 100 halls, but actual service did not begin until 2:15 PM in the dining room and was completed at 2:40 PM on the 100 hall. The Regional Dietary Manager, acting as interim dietary manager, confirmed that the delay was due to staffing issues in the kitchen, specifically that dietary aides had quit without notice on the night of 11/20/25, resulting in unwashed dishes that had to be cleaned the morning of 12/01/25. This caused breakfast to also be served two hours late, which in turn delayed lunch service. The Administrator acknowledged awareness of previous late dining services but had not identified staffing as the cause prior to this incident.
Failure to Submit PASRR Level II Evaluation for Resident with Serious Mental Illness
Penalty
Summary
The facility failed to submit a request for a Level II Preadmission Screening and Resident Review (PASRR) evaluation for a resident who was admitted with multiple serious mental health diagnoses. Documentation showed that the resident had a history of bipolar disorder, post-traumatic stress disorder (PTSD), depression, and anxiety, and was receiving several psychiatric medications, including antidepressants, antianxiety medications, and an antipsychotic. Despite these diagnoses and ongoing psychiatric symptoms, such as hallucinations, there was no evidence in the medical record that a Level II PASRR evaluation had been requested or completed. The resident's care plan addressed mood alterations, PTSD, and the risk of drug-related side effects, and included interventions such as psychiatric consultations and monitoring for medication effects. However, the care plan did not reference the need for a PASRR Level II evaluation. Medical and psychiatric notes documented ongoing symptoms, medication adjustments, and the addition of antipsychotic and antianxiety medications, but there was no indication that these changes prompted a reassessment of the resident's PASRR status. Interviews with facility staff revealed that the social worker relied on the hospital's PASRR Level I screening, which did not identify a serious mental illness, and assumed that all relevant diagnoses had been entered into the screening tool. The social worker acknowledged not submitting a Level II PASRR request after admission, despite the resident's diagnoses, medication changes, and reports of hallucinations. The administrator deferred to the social worker regarding PASRR requirements, and the clinical coordinator confirmed that no Level II evaluation had been submitted, as the Level I determination did not indicate a serious mental illness and there was no significant change in the resident's condition.
Failure to Maintain Emergency Tracheostomy Equipment and Sterile Technique
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for a resident with a tracheostomy by not ensuring that required emergency tracheostomy equipment, specifically an Ambu bag, was kept at the bedside as ordered and as required by facility policy. Observations revealed that while spare trach tubes and an obturator were present at the bedside, the Ambu bag was missing from the resident's room and could not be located by nursing staff on the crash cart. The Director of Nursing (DON) was also unaware of the facility's trach policy and confirmed the absence of the Ambu bag at the bedside after searching the room and surrounding areas. The Ambu bag was eventually found inside the crash cart, which was located 143 feet away from the resident's room, and staff were unable to immediately locate it when needed. Additionally, the facility failed to ensure proper infection-control practices during tracheostomy care for the resident. During an observed tracheostomy care procedure, a nurse contaminated her sterile gloves by holding the resident's hands and moving non-sterile items, but did not change gloves or reestablish sterility before continuing the procedure. The nurse proceeded to complete the tracheostomy care, including cleaning the stoma site and changing the inner cannula, while wearing contaminated gloves. The nurse reported having received training from another nurse on the floor and had shadowed for several days prior to performing tracheostomy care independently. Interviews with the Medical Director and Staff Development Coordinator confirmed concerns regarding the lack of sterile technique and the adequacy of staff training. The Staff Development Coordinator stated that new nurses were trained by more experienced floor nurses and received annual refresher training, but did not follow up to ensure correct training unless a deficiency was brought to her attention. The DON, who was new to the facility, acknowledged the importance of following proper protocol but was not familiar with the exact policy.
Failure to Serve Dietitian-Approved Pureed Bread Item
Penalty
Summary
The facility failed to follow the approved menu for a resident on a pureed diet. The dietitian-approved menu for Week 2 specified that residents requiring a pureed diet should receive pureed cornbread. One resident, admitted with dysphagia and physician orders for a pureed diet, was observed during tray line service to have received pureed chicken, pureed broccoli, and pureed candied yams, but no pureed cornbread or any pureed bread product was included on the tray. Staff confirmed that a pureed bread item was not prepared or served, and the omission was only addressed after surveyor intervention. Attempts to contact the Registered Dietitian at the time were unsuccessful.
Resident Subjected to Verbal Abuse and Threats by Housekeeper
Penalty
Summary
A resident with a history of cerebral vascular accident (stroke), who was cognitively intact and able to independently propel himself in a wheelchair, was subjected to verbal abuse by a staff member. The incident occurred when the resident was moving down a crowded hallway and was confronted by a housekeeper who became upset that the resident was blocking her cart. Multiple staff members witnessed the housekeeper cursing at the resident in a threatening tone, using profane and racially charged language, and physically pushing her housekeeping cart into the back of the resident's wheelchair. The housekeeper also yanked the resident's wheelchair and continued to verbally threaten and insult him, escalating the situation and causing the resident to become visibly upset. Witness statements from two nurse aides confirmed the sequence of events, including the housekeeper's repeated use of profanity, threats to physically harm the resident, and physical contact with the resident's wheelchair. The incident was substantiated as verbal abuse by the facility's investigation, with corroborating accounts from staff who intervened to separate the housekeeper from the resident and de-escalate the situation. The resident was taken to his room and calmed down after the incident. The facility's investigation confirmed the occurrence of verbal abuse and threats by the housekeeper toward the resident.
Failure to Protect Residents from Misappropriation and Exploitation
Penalty
Summary
The facility failed to protect residents from misappropriation of property and exploitation in two separate incidents involving two residents. In the first case, a resident with a diagnosis of dementia, assessed as moderately cognitively impaired, reported that her debit card account was depleted after she gave her card to a nurse aide to pay a utility bill. The nurse aide used the card for unauthorized purchases totaling over $2,200, including groceries, retail items, and rent payments. The resident became aware of the missing funds after checking her account balance and confronted the aide, who did not provide an explanation. Multiple staff members were informed of the incident, and the matter was reported to local law enforcement. The aide was suspended and later terminated following the investigation, and the resident was reimbursed for the unauthorized transactions. In the second incident, another resident, who was cognitively intact and had multiple medical diagnoses, was approached by a nurse aide who requested money to feed her children. The resident gave the aide $65 after being told $20 would not be sufficient. The aide promised to repay the money but did not do so and instructed the resident to misrepresent the reason for the transaction to other staff. The aide was suspended and subsequently terminated after the incident was reported and substantiated by facility staff. However, the facility did not reimburse the resident for the money given to the aide, with the administrator stating that the money was given voluntarily. Both incidents were substantiated through staff interviews, resident statements, and review of facility records. The facility's failure to prevent staff from soliciting or misusing residents' funds resulted in financial loss and emotional distress for the residents involved. The facility's policies defined such actions as exploitation and misappropriation of property, yet the protections in place were insufficient to prevent these occurrences.
Failure to Notify APS of Abuse and Misappropriation Allegations
Penalty
Summary
The facility failed to report allegations of abuse, neglect, and misappropriation of property/exploitation to Adult Protective Services (APS) for three residents. According to the facility's policy, the Administrator is responsible for reporting all investigation results of such incidents to the appropriate state agencies as required by law. However, documentation and staff interviews revealed that APS was not notified in several substantiated cases involving misappropriation of property and verbal abuse. In one case, a resident alleged that a nurse aide borrowed her debit card under the pretense of paying a bill, but subsequently, nearly the entire balance was depleted without authorization. The facility substantiated the misappropriation, reimbursed the resident, and notified law enforcement and the state agency, but there was no documentation that APS was informed. In another incident, a resident with a history of stroke was verbally abused and threatened by a housekeeper, who also physically pushed a cart into the resident's wheelchair. The facility substantiated the verbal abuse, but again, APS was not notified as required. A third resident, diagnosed with bipolar disorder and anxiety, reported a valuable ring missing after showing it to a nurse aide. The investigation noted the resident did not witness the theft but believed the aide was the only person aware of the ring's location. The facility's investigation report documented that APS was not notified of this allegation either. Interviews with former administrators and nursing staff confirmed a lack of clarity and adherence to the policy regarding APS notification in these cases.
Inaccurate Coding of Physician-Documented GDR Contraindication on MDS
Penalty
Summary
The facility failed to accurately code a physician-documented gradual dose reduction (GDR) as clinically contraindicated on the Minimum Data Set (MDS) assessment for one resident. Record review showed that the psychiatric provider documented that a dosage reduction to the resident's psychotropic regimen was likely to impair function and worsen the underlying psychiatric condition. However, the annual MDS assessment did not reflect that the physician had documented the GDR as clinically contraindicated. During interviews, the MDS nurse confirmed she completed the relevant section of the MDS and acknowledged that she incorrectly marked the GDR as not clinically contraindicated, which was an error. The administrator confirmed the expectation for MDS assessments to be accurate.
Inaccurate MDS Coding for Multiple Residents
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) assessments for four residents in various areas, including medications, smoking, elimination, and behaviors. Resident #14, who was diagnosed with Diabetes Mellitus, was not coded for receiving hypoglycemic medications despite having multiple physician orders for insulin and other diabetes medications. The MDS Nurse acknowledged the error, attributing it to human error, and both the Interim Director of Nursing and the Administrator confirmed that the MDS should have been coded accurately. Resident #17, who had a history of smoking, was not coded for tobacco use in the MDS assessment, despite being cognitively intact and actively using the facility's designated smoking area. The MDS Nurse admitted to clicking the wrong answer on the MDS screen, and both the Interim Director of Nursing and the Administrator agreed that the assessment should have reflected the resident's smoking status. Resident #2, with a diagnosis of colostomy, was not coded for an ostomy in the MDS assessment, which was acknowledged as an error by the MDS Coordinator and the Interim Director of Nursing. Additionally, Resident #13, who had dementia, was not coded for a gradual dose reduction attempt of antipsychotic medication, despite documentation in the care plan and a pharmacy consultant report indicating such an attempt. The MDS Nurse recognized this as an oversight, and the Interim Administrator confirmed the assessment should have been coded to reflect the dose reduction attempt.
Failure to Assess Resident's Ability to Self-Administer Medications
Penalty
Summary
The facility failed to assess a resident's ability to self-administer medications before leaving medications on the overbed table in the resident's room. The resident, who was cognitively intact, had medications left on her overbed table to take at her discretion, without a documented assessment or physician's order for self-administration. The medications included Acetaminophen and Ciprofloxacin, which were left in separate medication cups on the overbed table. Nurse #1 admitted to leaving the medications on the overbed table after observing the resident with a medication cup at her mouth. The nurse acknowledged that he should have stayed with the resident to ensure the medications were taken. The Assistant Director of Nursing and the Interim Director of Nursing confirmed that the resident had not been assessed for self-administration and that the nurse should have supervised the medication administration.
Failure to Provide Required CMS Notices
Penalty
Summary
The facility failed to provide the required Centers for Medicare and Medicaid Services (CMS) Notice of Medicare Non-Coverage (NOMNC) and the Skilled Nursing Facility Advanced Beneficiary Notice (ABN) for a resident reviewed for beneficiary protection notification. The resident was admitted with Medicare Part A skilled services and had moderate cognitive impairment. Her Medicare Part A skilled services ended, but her benefit was not exhausted, and she remained in the facility. There was no evidence that the resident or her responsible party received the necessary NOMNC or ABN notices. The Business Office Manager stated that the former weekday Receptionist was responsible for completing the required forms, but the Receptionist was no longer employed, and the forms were not uploaded to the facility system. Blank forms were found in the resident's folder. The Administrator confirmed that the resident should have received the CMS-10123-NOMNC and CMS-ABN as required by federal guidelines.
Failure to Refer Resident for PASARR Evaluation
Penalty
Summary
The facility failed to refer a resident with a new diagnosis of mental illness for a Preadmission Screening and Resident Review (PASARR) evaluation. Resident #33, who was admitted with a diagnosis of adjustment disorder, was newly diagnosed with post-traumatic stress disorder (PTSD) on June 27, 2024. Despite this new diagnosis, the resident's quarterly Minimum Data Set (MDS) assessment did not indicate that she was screened for a PASARR evaluation. The resident's care plan, last reviewed on July 29, 2024, included interventions for behaviors related to a traumatic event, but did not include a referral for a PASARR evaluation. Interviews conducted during the investigation revealed that the facility's Social Worker did not refer Resident #33 for a PASARR evaluation because she believed the resident was doing well and was unaware of the resident's nightmares. The resident reported experiencing nightmares after being contacted by a family member who had previously assaulted her. The facility Administrator confirmed that a new psychiatric diagnosis should have prompted a referral to the North Carolina Medical Uniform Screening Tool (NC MUST) for a PASARR application, which the Social Worker failed to do.
Failure to Document Medication Administration
Penalty
Summary
The facility failed to maintain an accurate medical record for a resident, specifically in documenting the administration of medication. Resident #18, who was admitted with a diagnosis of peripheral vascular disease, had a physician's order for Acetaminophen 325 mg tablets, to be given as needed for pain or fever. On October 14, 2024, Nurse #1 was observed administering 650 mg of Acetaminophen to Resident #18, but this administration was not recorded in the resident's Medication Administration Record (MAR) for October 2024. Additionally, there was no nursing documentation in the medical record indicating that the medication was administered. In a subsequent interview, Nurse #1 stated that he believed he had documented the administration on the MAR, while the Interim Director of Nursing confirmed that the documentation should have been completed after the medication was given.
Failure to Maintain Safe and Clean Environment in Resident's Room
Penalty
Summary
The facility failed to maintain a safe, clean, and comfortable environment for a resident, as evidenced by the condition of the bathroom door and doorway in the resident's room. Observations revealed that the bathroom door was scuffed and had peeling paint, exposing a wood-like color underneath. Additionally, there was a buildup of black debris on the grout at the base of the bathroom doorway. The resident expressed dissatisfaction with the condition of the bathroom and reported having informed staff about these issues multiple times, although she could not recall specific staff members or dates. Interviews with facility staff, including the Assistant Maintenance Director, Housekeeping Supervisor, Maintenance Director, Administrator, and interim Director of Nursing, revealed a lack of awareness and documentation regarding the resident's complaints. The Assistant Maintenance Director confirmed that room inspections were conducted monthly, and maintenance issues were logged in a book at the nurse's station and an electronic work order system, both checked weekly. However, no work order for the resident's room was found. The Housekeeping Supervisor was unaware of the discoloration, and the Administrator, who conducted daily ambassador rounds, did not notice any issues. The interim DON stated that nursing staff were expected to notify housekeeping and maintenance of any cleaning or repair needs.
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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