Smithfield Manor Rehabilitation And Healthcare Cen
Inspection history, citations, penalties and survey trends for this long-term care facility in Smithfield, North Carolina.
- Location
- 902 Berkshire Road, Smithfield, North Carolina 27577
- CMS Provider Number
- 345175
- Inspections on file
- 21
- Latest survey
- April 23, 2026
- Citations (last 12 mo.)
- 7 (1 serious)
Citation history
Health deficiencies cited at Smithfield Manor Rehabilitation And Healthcare Cen during CMS and state inspections, most recent first.
The facility failed to ensure adequate washcloths and towels were available for residents’ ADL care, resulting in multiple cognitively intact residents on two halls reporting difficulty obtaining linens for bathing, missed baths, and the need to purchase their own washcloths. Staff across all shifts described an ongoing linen shortage over many months, stating that residents sometimes did not receive scheduled showers or bed baths and that they resorted to using sheets, pillowcases, cut-up blankets, clothing protectors, wipes, and paper towels instead of proper linens. Observations of linen rooms repeatedly showed no or very few towels and no washcloths despite high resident census. Environmental services and laundry staff reported stocking limited numbers of washcloths and towels based only on scheduled shower days, having no system to track soiled linens returned, no emergency stock, and no total inventory count. Nursing and supervisory staff stated they frequently reported the shortages to administration, while leadership acknowledged awareness of the problem but continued to provide insufficient quantities of linens to the halls.
Surveyors found that kitchen equipment and food contact surfaces were not maintained in a clean, sanitary condition. Shelves under two steam tables were covered with dried, sticky food particles, door handles on two reach-in refrigerators and a hot box/warmer had dried food debris, and a three-cylinder pellet plate warmer contained dried food particles in all cylinders. These unsanitary conditions were observed on multiple days despite written cleaning schedules requiring thorough cleaning of the steam tables and pellet warmer, and expectations that staff wipe down steam tables after each meal and clean door handles and the plate warmer daily.
A cognitively intact resident with chronic ankle pain had a PRN order for Oxycodone 5 mg, and pharmacy records showed that two narcotic cards (88 tablets total) were delivered and placed on a med cart with corresponding narcotic sheets. A nurse on second shift confirmed receiving and counting both cards, and subsequent nurses on night and day shifts reported correct narcotic counts, though one did not recall how many Oxycodone cards were present. During a later shift-change count, a nurse discovered that one full Oxycodone card (44 tablets) and its associated shift-change count sheet and narcotic countdown sheet were missing, and the medication could not be located, resulting in misappropriation of the resident’s narcotic medication.
A resident with COPD, heart failure, dementia, lower extremity limitations, and a high fall risk, who required substantial assistance for bed mobility and incontinence care, rolled off the bed during incontinence care when an agency NA raised the bed, unfastened the brief, and partially cleaned the resident. While the resident used an overhead trapeze bar to turn, the NA, unfamiliar with the resident and working a double shift, took her hands and eyes off the resident to prepare a clean brief, and the resident rolled off the opposite side of the bed onto the floor. The DON later confirmed that staff were expected to prevent residents from rolling off the bed and that the NA had not been observing or maintaining contact with the resident at the time of the fall.
Surveyors found expired and improperly dated medications on one of four medication carts, including an open bottle of zinc sulfate with a past manufacturer’s expiration date and illegible open date, and two open multi-dose insulin pens (lispro and glargine) with handwritten open dates but no documented discard dates. The insulin pens were stored in a clear plastic bag labeled by the pharmacy with a later expiration date, which an RN relied upon instead of discarding the pens 28 days after opening. The RN reported only checking floor stock medication expirations when administering, not routinely reviewing all stock, while the pharmacist confirmed the 28-day discard requirement and the DON and Administrator stated their expectation that nursing staff and medication aides check carts daily and remove expired medications.
A resident with osteoporosis and dementia, requiring two-person assistance for ADLs, fell and sustained a leg fracture when only one nurse aide provided incontinence care and rolled the resident away from herself. The aide did not follow the care guide, and a discrepancy existed between therapy recommendations and the care plan, leading to the resident not receiving the required assistance and resulting in injury.
A resident with multiple comorbidities, including neuropathy and a left leg amputation, was injured when her wheelchair tipped backward in a facility van due to improper securement by the Transport Driver, who attached all four anchor straps to the rear wheels instead of the wheelchair frame. The resident suffered neck and back pain, a tongue laceration, and a hand abrasion, requiring hospital evaluation before returning to the facility.
The facility failed to provide opportunities for residents to formulate advance directives and maintain accurate documentation. Several residents lacked documentation of advance directive education, and one resident's care plan inaccurately reflected their code status. Staff interviews revealed assumptions about discussions that were not documented, highlighting systemic issues in communication and documentation of residents' wishes.
A facility failed to accurately code MDS assessments for several residents, leading to deficiencies in skin conditions, bowel and bladder, nutritional status, and discharge. A resident with a surgical wound was not coded for wound care, another with a urostomy was incorrectly coded for catheters, a cognitively impaired resident receiving tube feeding was not coded for a gastrostomy tube, and a resident's discharge was inaccurately recorded. Staff interviews confirmed these errors.
The facility failed to update nutritional care plans for three residents experiencing weight loss, despite physician orders and dietary recommendations. The care plans did not address the risk of decreased nutritional status, and staff interviews revealed that the Dietary Manager had not completed the necessary updates.
A resident receiving oxygen therapy was at risk due to the application of petroleum jelly, a flammable substance, on their lips. Despite the known risks, the facility continued this practice as per a physician's order. Interviews with staff revealed a lack of awareness about the potential hazard, leading to a deficiency in accident prevention.
A resident with hypoxia was prescribed 1L of oxygen via nasal cannula, but observations revealed the oxygen concentrator was set at 2L. Despite the incorrect setting, the resident showed no distress. Staff interviews confirmed the discrepancy, and the Medical Director noted no harm occurred from the higher oxygen level.
A medication cart was found unlocked and unattended in a hallway near an entrance, with no staff or residents nearby. A nurse later acknowledged the cart should have been locked when unattended, but did not provide a reason for the oversight. The DON confirmed the expectation for the cart to be locked at all times when not attended.
A resident with multiple medical comorbidities and on blood thinning medication was left unattended by a Nursing Assistant (NA) during Activities of Daily Living (ADL) care, despite requiring 2 person assistance. The resident fell from the bed, resulting in a closed fracture of the left distal femur and a small skin tear to the left elbow. The injury led to complications and the resident's subsequent death. The incident highlighted the facility's failure to adhere to the care plan and ensure proper supervision, resulting in Immediate Jeopardy.
A dependent resident with multiple comorbidities, including chronic atrial fibrillation, heart failure, diabetes mellitus, and peripheral artery disease, required two-person assistance for bed mobility, incontinence care, and bathing. Despite this, a Nursing Assistant (NA) provided care independently, resulting in the resident falling from the bed and sustaining a closed fracture of the left distal femur and a skin tear to the left elbow. The incident occurred when the NA left the resident unattended to retrieve a washcloth. The resident's care plan had clearly indicated the need for two-person assistance due to impaired mobility and other risk factors.
Failure to Provide Adequate Washcloths and Towels for Resident ADL Care
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate washcloths and towels for residents and staff to complete Activities of Daily Living (ADL) care, resulting in residents going without regular showers or bed baths and staff resorting to inappropriate substitutes. On multiple observations of the East and [NAME] Halls’ linen rooms, surveyors found no towels or washcloths available, or only a very limited number of towels and no washcloths, despite census counts of approximately 56 and 53 residents on those halls. Residents reported ongoing difficulty obtaining basic linens for bathing and personal hygiene, with some stating they had to purchase their own washcloths and could not bathe when they wished. Staff interviews consistently described a chronic shortage of washcloths and towels beginning around March–May 2025, leading to missed baths and the use of items such as sheets, pillowcases, blankets, clothing protectors, paper towels, and disposable wipes in place of proper linens. Several cognitively intact residents who required varying levels of assistance with bathing and toileting reported specific impacts from the linen shortages. One resident on [NAME] Hall, who was frequently incontinent of urine and always incontinent of bowel and required substantial/maximal assistance with bathing and toileting, had ADL documentation over nearly three months showing only two showers and seven bed baths despite scheduled shower days twice weekly. She stated she was unable to shower or bathe daily due to lack of washcloths and towels and had purchased her own washcloths. Another resident on [NAME] Hall, who required set-up or clean-up assistance and was occasionally incontinent, reported trouble getting washcloths and said she used disposable wipes or paper towels when linens were unavailable and had also bought her own washcloths. On East Hall, multiple residents who were incontinent and required partial to maximal assistance with bathing and toileting reported missing baths, receiving only one washcloth and no towel for ADL care, or being unable to clean up when they wanted, with one resident stating the problem had existed since admission and another stating she purchased and labeled her own washcloths. Nursing and nurse aide staff across all shifts described routine shortages of washcloths and towels and the resulting care limitations. NAs reported that on a typical assignment of about 12 residents, they would normally use two washcloths and one towel per resident, but when supplies were short, they limited showers/bed baths to scheduled days only, used one towel for both washing and drying, or substituted sheets, pillowcases, cut-up blankets, clothing protectors, wipes, or paper towels. Some NAs stated that residents missed scheduled baths or showers because there were no washcloths or towels available. Nurses and nurse supervisors reported that staff frequently informed them there were no clean linens, that residents were told they had to wait for laundry to be done, and that some residents and staff purchased their own washcloths. Supervisory staff acknowledged that residents had gone without showers/bed baths due to lack of linens and that concerns were reported to administration repeatedly. The Environmental Services Director and laundry staff described a linen process that did not ensure sufficient washcloths and towels were available for all residents’ daily ADL needs. Laundry staff began work at 6:30 AM, collected soiled linens, and stocked three linen rooms at set times during the day, but there was no system to count soiled washcloths and towels returned to laundry, and no total inventory count of available linens. Documentation showed that East and [NAME] Halls received on average only about 30 washcloths and 16 towels each, based on scheduled shower days rather than the full census of residents. The Environmental Services Director stated he followed administration’s guidance to provide enough linens for residents scheduled for showers, acknowledged there was no emergency stock, and confirmed awareness that staff were cutting up blankets and using pillowcases for care. He also reported seeing soiled washcloths and towels discarded in trash cans and stated he informed the Administrator of the need for more linens. The DON stated she did not know the exact timing of linen cart deliveries, was unaware of residents missing showers/bed baths due to linen shortages, and indicated she would need linen counts and census information to address the issue. The Administrator acknowledged hearing about washcloth and towel shortages from staff, was aware of current concerns about lack of linens for daily showers/bed baths, and confirmed that additional towels and washcloths kept in her office were only accessible when she was present, while the overall linen distribution to the halls remained insufficient for the number of residents.
Failure to Maintain Sanitary Kitchen Equipment and Food Contact Surfaces
Penalty
Summary
The deficiency involves the facility’s failure to maintain kitchen equipment in a clean and sanitary condition as required by professional standards and the facility’s own cleaning schedules. Surveyors observed that both 5-foot shelves under two steam tables were covered with dark, dried food particles and were sticky to the touch. The door handles of two reach-in refrigerators and one hot box/warmer were also noted to have dried food particles. In addition, the three-cylinder pellet plate warmer dispenser contained dried food particles in the bottom of all three cylinders. These conditions were identified during a kitchen tour with the Clinical Registered Dietitian. On a subsequent observation two days later, the same unsanitary conditions persisted: the shelves under the steam tables remained dirty, the reach-in refrigerator and hot box/warmer door handles still had dried food particles, and the pellet plate warmer cylinders continued to contain dried food debris. Review of the undated morning cleaning schedule showed that staff were expected to clean under both steam tables thoroughly, including the legs, on Mondays, and the dietary aide daily cleaning schedule required cleaning and polishing of the pellet warmer on Mondays. In interviews, the morning dietary staff member stated they were training new staff and did not get to clean the steam table, while the Certified Dietary Manager and the Administrator both acknowledged that staff were expected to wipe down the steam tables after every meal and clean the door handles and plate warmer daily.
Misappropriation and Loss of Resident’s Oxycodone and Narcotic Documentation
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident’s property by preventing the misappropriation of a controlled narcotic medication, Oxycodone 5 mg, prescribed PRN for ankle pain. The resident was cognitively intact and had a physician’s order for Oxycodone 5 mg every 6 hours as needed. Pharmacy packing slips showed that two medication cards, each containing 44 tablets (total 88 tablets), were delivered and accepted on the same date by a nurse supervisor. The narcotic countdown sheet labeled as card #2 of 2 documented receipt of 44 tablets and was verified by two nurses, but the narcotic countdown sheet for card #1 of 2 was missing. According to staff interviews and records, the two Oxycodone cards were initially added to the medication cart and the corresponding narcotic sheets were placed in the narcotic book. A nurse on the second shift reported that the narcotic count was correct at the end of his shift when he received and placed both cards in the cart. The night-shift nurse who followed stated her narcotic count was correct at the end of her shift but did not recall how many Oxycodone cards were present. Another nurse working the first shift the next day recalled seeing only one Oxycodone card for the resident and stated there was nothing to alert her that a second card should have been present if the narcotic countdown sheet was not on the cart. During a subsequent shift-change narcotic count between first and second shift nurses two days after delivery, the second-shift nurse identified that one Oxycodone card containing 44 tablets was missing, along with the associated shift change count sheet and narcotic countdown sheet. This nurse recognized the discrepancy because he had personally received and placed both Oxycodone cards in the cart earlier. Other nurses who worked intervening shifts reported that their narcotic counts were correct and that they maintained possession of the medication cart keys while on duty. Despite these accounts, the facility was unable to locate the missing Oxycodone card or the related documentation, resulting in an unresolved loss of the resident’s narcotic medication and associated records.
Resident Falls From Bed During Incontinence Care Due to Lack of Supervision
Penalty
Summary
The facility failed to ensure a resident’s environment was free from accident hazards and that adequate supervision was provided during incontinence care, resulting in the resident rolling off the bed onto the floor. The resident had COPD, heart failure, atherosclerotic heart disease, dementia, functional limitations in both lower extremities, and was identified as high risk for falls. A recent MDS showed moderate cognitive impairment and dependence on staff for toileting and substantial/maximal assistance for rolling in bed. The care plan required staff assistance with repositioning and incontinence care. On the night of the incident, an agency nursing assistant, unfamiliar with the resident’s care needs and working a double shift, raised the bed to about three feet from the floor to provide incontinence care, unfastened the resident’s brief, and partially cleaned the resident. During this care, the resident, lying on her back in the center of the bed, used an overhead trapeze bar to begin turning from her back to her right side. The nursing assistant was positioned near the head of the bed on the left side and took both her hands and eyes off the resident to prepare the clean brief, which was within reach. While the assistant was looking down and not maintaining observation or physical contact, the resident rolled off the opposite side of the bed onto the floor. The assistant reported she did not know how or why the resident rolled off because she was not watching the resident at that moment. Another nursing assistant, who regularly worked with the resident, confirmed the presence of the trapeze bar used by the resident to turn for incontinence care. The DON stated that staff were expected to provide care so residents did not roll off the bed and confirmed that the assistant had taken her eyes off the resident and had no hands on the resident when the resident used the trapeze bar and rolled off the bed.
Expired Medications and Improper Dating on Medication Cart
Penalty
Summary
The deficiency involves failure to ensure medications were properly labeled and stored, specifically related to expired and improperly dated drugs on one of four medication carts (Upper East Medication Cart). During an observation of this cart with a nurse, surveyors found an open bottle of floor stock zinc sulfate 50 mg tablets with a manufacturer’s expiration date of 2/2026 circled in red and an illegible handwritten open date on the bottle. They also found one open insulin lispro injector pen with a handwritten open date of 3/8/26 and no handwritten expiration date, and one open insulin glargine injector pen with a handwritten open date of 3/5/26 and no handwritten expiration date. Both insulin pens had manufacturer’s expiration dates in 2027 and were stored together in a clear plastic bag with a pharmacy label on the outside listing an expiration date of 4/10/27. During the observation, the nurse stated she checked expiration dates of floor stock medications only when pulling them to administer and did not check all floor stock medications for expiration dates, acknowledging she did not know the zinc sulfate was expired. She also stated she relied on the expiration date on the outside of the pharmacy bag for the insulin pens instead of following the handwritten opened dates on the pens and discarding them after 28 days. The pharmacist confirmed that the insulin pens should have been discarded 28 days after opening and that the zinc sulfate should have been discarded after 2/2026. In a separate interview, the DON and Administrator stated that nurses were responsible for checking medication carts daily for expired medications and discarding any expired medications, and that their expectation was that nursing staff, including medication aides, would check the carts daily and ensure there were no expired medications present.
Failure to Provide Required Assistance During Bed Mobility Results in Resident Fall and Fracture
Penalty
Summary
A deficiency occurred when a resident with osteoporosis, atrial fibrillation, and dementia sustained a left distal tibia and fibula fracture after rolling out of bed during incontinence care. The resident was on an anticoagulant and had a care plan indicating the need for assistance from two staff members for activities of daily living (ADLs) due to impaired mobility, poor safety awareness, and impulsiveness. However, at the time of the incident, only one nurse aide was providing care, and the resident was rolled away from the aide, resulting in the resident sliding off the bed and falling to the floor. The nurse aide involved did not request assistance from another staff member, despite the care guide indicating a two-person assist was required for ADLs. The aide also rolled the resident away from herself, rather than towards herself, which contributed to the resident's fall. The bed was raised to the aide's waist height, and the resident was positioned in the middle of the bed before care began, but during the process, the resident attempted to assist and rolled too far, leading to the fall. At the time of the incident, there was a discrepancy between the physical therapy discharge summary, which indicated the resident required supervision/touch assistance from one staff member for bed mobility, and the care plan and care guide, which still required two-person assistance. The therapy department had notified nursing of the change, but the care plan and care guide had not yet been updated. This lack of timely communication and failure to follow the existing care plan resulted in the resident not receiving the required level of assistance, directly leading to the accident and injury.
Failure to Properly Secure Wheelchair During Transport Results in Resident Injury
Penalty
Summary
A deficiency occurred when facility staff failed to follow the manufacturer's instructions for securing a wheelchair in the facility's transportation van. The Transport Driver incorrectly anchored all four securement straps to the rear wheels of the wheelchair, leaving the front of the wheelchair unsecured. According to the manufacturer's instructions, tie-down hooks should be attached to solid frame members near seat level and not to wheels, plastic, or removable parts. This improper anchoring allowed the wheelchair to tip backward during vehicle acceleration. The incident involved a resident with multiple medical conditions, including neuropathy, chronic ischemic heart disease, osteomyelitis, diabetes, and a left leg above-knee amputation. The resident was cognitively intact, dependent on staff for transfers, and required assistance with wheelchair mobility. During transport to a dental appointment, the resident's wheelchair tipped backward when the van accelerated from a stop, causing her to fall and strike her head and back on the floor of the van. The resident was wearing a seatbelt at the time of the incident. As a result of the fall, the resident experienced posterior neck and upper back pain, a superficial laceration on the tongue, paraspinal tenderness in the upper thoracic region, and a superficial abrasion on the right hand. She was transported to the hospital, where CT scans showed no evidence of hemorrhage or acute fracture, and she was discharged back to the facility later that evening. The investigation confirmed that the Transport Driver had attached both front and rear anchor straps to the rear wheels, leaving the wheelchair frame free to rotate and tip over during transport.
Removal Plan
- Resident #1's wheelchair tipped backwards in the facility transportation van due to the transportation driver failing to follow manufacturer's instructions for wheelchair securement. The driver had improperly anchored both left and right front and rear straps to the rear wheels, leaving the front of the wheelchair unsecured. When the vehicle accelerated, the wheelchair tipped backwards, causing Resident #1's head and back to strike the floor of the van. Emergency services were called, and Resident #1 was transported to the hospital where she was treated for posterior neck pain, upper back pain, a superficial tongue laceration, paraspinal tenderness, and a superficial abrasion to her right hand. A CT scan revealed no evidence of hemorrhage or acute fracture, and the resident was discharged back to the facility.
- The transportation driver was removed from driving duties pending retraining and competency validation.
- The facility conducted a 100% audit of progress notes, transport log and interview with the Transportation Driver of in-house facility residents' transports for the past 90 days by the Assistant Director of Nursing, with no concerns identified.
- The Assistant Director of Nursing reviewed the transport log to identify any resident that would potentially be transported with facility van. No residents were to be transported until investigation and retraining completed.
- All scheduled appointments were scheduled by the Transportation Driver with a contracted outside transportation company.
- The facility has two employees who drive the transportation van. The Transportation Driver is the primary driver and the Maintenance Director is the back up driver.
- The Administrator audited the transport employee files: audit to include training, valid driver's license, van maintenance checklist to include proper alignment of the wheelchair between the tie down straps, attaching the rear tie down straps to the rear frame, front tie down straps to the front frame, ensuring tightness on both the front and rear tie downs, and securing seatbelt around resident, and employee vehicle policy to include but not limited to vehicle purpose, driver licensing, maintenance of company van, proof of insurance on company van, traffic violations, usage of cellular phone, accidents involving company vehicle, theft of company vehicle and driver responsibilities in regards to operation of vehicle, use of seatbelts and securement devices and reporting requirements with no concerns identified.
- The Maintenance Director did the initial education for the Transportation Driver on site of incident and return demonstration.
- The Administrator reviewed the manufacturer's video and training documents provided by the facility and re-educated post incident.
- The Maintenance Director conducted education and an initial return demonstration with the Transportation Driver, Director of Nursing and Administrator that included proper securement of the wheelchair and van anchors per manufacturer's instructions.
- Outside Maintenance Director from a sister facility provided additional education to the Administrator, Maintenance Director and Transportation Driver regarding proper securement of the wheelchair and van anchors per manufacturer's instructions.
- The Administrator initiated 100% in-service with the Maintenance Director and Transportation Driver about proper securement of wheelchairs during transport per manufacturer's instructions. The in-service was completed.
- All newly hired Transport Drivers will be in-serviced by the Maintenance Director during orientation to include the skills check list. The skills check list includes but is not limited to a competency validation of loading, securing and unloading a resident and a return demonstration.
- The Maintenance Director sent the van out for inspection that included checking functional status of the wheelchair anchors with no concerns identified.
- The facility initiated 10% audit of all residents being transported by the facility to be completed by the Maintenance Director weekly then monthly utilizing the Van Transport Audit Tool to ensure proper securing of the resident before leaving the facility and this was taken to Quality Assurance committee meeting. This audit is an observational audit to determine proper securement of the resident, wheelchair, and van anchors. The results will be documented on the Van Transport Audit Tool. All areas of concern will be addressed by the Administrator and/or Maintenance Director immediately.
- The Administrator will forward the results of the Van Transport Audit Tool to the Executive Quality Assurance Committee to include Administrator, Director of Nursing, Assistant Director of Nursing, Quality Assurance Nurse, Infection Control Preventionist/Staff Development Nurse, Activities Director, social workers, unit managers and unit coordinators, Maintenance Director, Minimum Data Set nurse, Dietary Manager, Medical Director and additional staff representatives monthly for review to determine trends and / or issues that may need further interventions put into place and to determine the need for further and / or frequency of monitoring.
Deficiency in Advance Directive Documentation and Code Status Accuracy
Penalty
Summary
The facility failed to provide an opportunity for residents to formulate advance directives and maintain accurate documentation of these directives in the medical records. Specifically, for five residents reviewed, there was no documentation indicating that education regarding advance directives was offered. This included residents with various medical conditions such as spinal cord disease, chronic obstructive pulmonary disease, pyothorax, chronic ischemic heart disease, and type 2 diabetes mellitus. Interviews with staff revealed that discussions about advance directives were assumed to occur but were not documented, leading to a lack of evidence that residents were informed about their rights to formulate these directives. Additionally, there was a discrepancy in the documentation of a resident's code status. One resident, who was severely cognitively impaired, had a care plan indicating a full code status, despite having a documented preference for Do Not Resuscitate (DNR) in their hard chart and physician's orders. This error was acknowledged by the MDS Nurse responsible for updating the care plan, who admitted to entering the incorrect code status by mistake. The Director of Nursing confirmed that care plans should accurately reflect the resident's wishes, and this discrepancy was discussed in morning meetings. The report highlights a systemic issue within the facility regarding the documentation and communication of advance directives and code status. Staff interviews revealed a lack of consistent procedures for discussing and documenting these critical aspects of resident care, leading to potential confusion and misalignment with residents' wishes. The facility's failure to ensure accurate and complete documentation of advance directives and code status represents a significant deficiency in meeting residents' rights and care needs.
Inaccurate MDS Coding for Multiple Residents
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) assessments for four residents, leading to deficiencies in the areas of skin conditions, bowel and bladder, nutritional status, and discharge. Resident #129, who was readmitted with a transmetatarsal amputation and a surgical wound treated with a wound vacuum, was inaccurately coded on the MDS as having no surgical wound or receiving wound care. The MDS Coordinator acknowledged the error, stating the data was not reviewed for accuracy before transmission. Resident #31, who had a urostomy due to bladder cancer, was incorrectly coded on the MDS as having an indwelling and external urinary catheter, despite nursing documentation and staff interviews confirming the presence of only a urostomy. The MDS Coordinator admitted the coding error, noting that the resident should not have been coded for catheters they did not have. Resident #5, who was severely cognitively impaired and receiving tube feeding, was not coded for having a gastrostomy tube on the MDS. The Food Service Director, responsible for coding the nutrition section, admitted the oversight. Additionally, Resident #134's discharge MDS was inaccurately coded as discharged to an acute hospital, while progress notes indicated a discharge to an assisted living facility. The MDS Coordinator confirmed the incorrect coding, and the Director of Nursing emphasized the need for accurate MDS coding.
Failure to Update Nutritional Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement individualized, person-centered care plans addressing the nutritional needs of three residents, leading to deficiencies in their care. Resident #67, who was admitted with a diagnosis of diabetes mellitus, experienced significant weight loss over several months. Despite physician orders for dietary interventions and recommendations from a registered dietician, Resident #67's care plan did not address the risk of decreased nutritional status or weight loss. The care plan was last reviewed on December 10, 2024, but did not include necessary updates to reflect the resident's nutritional needs. Resident #122, admitted with a diagnosis of depression, also experienced weight loss and required dietary modifications due to dysphagia. Although dietary notes and physician orders indicated the need for nutritional supplements and a change in diet consistency, Resident #122's care plan was not updated to address the risk of decreased nutritional status or weight loss. The care plan was last reviewed on December 5, 2024, but failed to incorporate the necessary interventions to support the resident's nutritional health. Resident #19, with diagnoses including diabetes mellitus, dementia, and depression, showed a pattern of weight loss over several months. Despite physician orders for dietary supplements and monitoring, the care plan did not address the risk of decreased nutritional status or weight loss. The care plan was last reviewed on December 3, 2024, without necessary updates. Interviews with facility staff revealed that the Dietary Manager was responsible for updating care plans but had not completed the task, leading to the deficiencies identified in the residents' care plans.
Use of Petroleum Jelly on Resident with Oxygen Therapy
Penalty
Summary
The facility failed to protect a resident from a potential flammable hazard by using petroleum jelly on a resident receiving oxygen therapy. The resident, who was severely cognitively impaired and dependent on staff for all activities of daily living, was prescribed oxygen therapy to manage hypoxia. Despite the known risks associated with using petroleum-based products in conjunction with oxygen therapy, the facility continued to apply white petroleum jelly to the resident's lips as per a physician's order. Interviews with various staff members, including a nurse, the Director of Nursing, the Pharmacist Consultant, and the Medical Director, revealed a lack of awareness and understanding of the potential hazard posed by petroleum jelly in this context. The Sales Representative from an oxygen concentrator repair company also acknowledged the risk, albeit small, associated with the use of petroleum jelly. The facility's failure to recognize and address this risk resulted in a deficiency related to accident hazards and inadequate supervision to prevent accidents.
Failure to Administer Oxygen as Prescribed
Penalty
Summary
The facility failed to provide supplemental oxygen as ordered by the physician for a resident diagnosed with hypoxia. The resident was readmitted to the facility with a care plan that included oxygen therapy at 1 liter via nasal cannula to maintain oxygen saturation rates greater than 94%. However, observations revealed that the resident's in-room oxygen concentrator was set at 2 liters instead of the prescribed 1 liter. Despite the incorrect setting, the resident showed no signs or symptoms of respiratory distress during the observations. Interviews with staff, including a nurse, the Quality Coordinator, and the Director of Nursing, confirmed that the oxygen setting was not in accordance with the physician's order. The nurse verified the order for 1 liter of oxygen and acknowledged that nurses should check the oxygen concentrators every shift to ensure the correct setting. The Quality Coordinator suggested that the knob might have been accidentally bumped, and the Director of Nursing reiterated the importance of daily checks. The Medical Director confirmed that the oxygen should have been set at the ordered liter, although there was no harm to the resident from the higher oxygen level.
Medication Cart Left Unlocked and Unattended
Penalty
Summary
The facility failed to secure residents' medications in a locked medication cart, as observed on the 200-hall upper west medication cart. On the morning of January 24, 2025, the medication cart was found unlocked and unattended outside the nurse's station, approximately 15 feet from an unlocked entrance to the facility. No staff or residents were present in the vicinity of the cart at that time. Shortly after, a nurse was seen exiting a resident's room and walking towards the unlocked cart. During an interview, the nurse acknowledged that the cart should have been locked when unattended but did not provide a reason for the oversight. The Director of Nursing confirmed that the cart was expected to be locked at all times when not attended by the nurse.
Failure to Provide Required Assistance Leads to Resident Injury and Death
Penalty
Summary
The facility failed to protect a resident's right to be free from neglect, as evidenced by an incident involving Resident #1. On 3/4/24, Nursing Assistant (NA) #1 neglected to provide the required 2 person assistance with Activities of Daily Living (ADL) care to Resident #1, who had multiple medical comorbidities and was on a blood thinning medication, making him vulnerable to injury. During care, NA #1 left Resident #1 unattended on his right side on the bed at waist height, resulting in the resident rolling off the bed and sustaining a closed fracture of the left distal femur and a small skin tear to the left elbow. The resident's vulnerability and the failure to adhere to the care plan led to serious harm, ultimately resulting in the resident's death due to complications of the left femur fracture. The neglect incident was brought to light when the Director of Nursing (DON) became aware of Resident #1's allegation of neglect, which occurred on 3/4/24 during a bath where the aide turned away from the bed, leading to the resident's fall. The investigation report revealed that NA #1 was aware of the 2 person ADL care requirement for Resident #1 but chose to provide care independently, resulting in the fall and serious bodily injury to the resident. The facility was notified of Immediate Jeopardy on 4/17/24, highlighting the severity of the deficiency in providing safe and appropriate care to vulnerable residents. The deficiency was further emphasized by the facility's failure to ensure proper supervision to prevent accidents for Resident #1, who required 2 person assistance with ADL care. The lack of adherence to the care plan, coupled with the resident's high risk for injury, led to the immediate jeopardy situation on 3/4/24.
Failure to Provide Adequate ADL Assistance Leads to Resident Injury
Penalty
Summary
The deficiency identified in the report pertains to a failure in providing safe Activities of Daily Living (ADL) care to a dependent resident, resulting in a serious adverse outcome. Resident #1, a heavy-set individual with multiple comorbidities including chronic atrial fibrillation, heart failure, diabetes mellitus, and peripheral artery disease, was assessed as dependent for bed mobility, incontinence care, and bathing. Despite being designated as a two-person assist for ADL care due to impaired mobility and other risk factors, Resident #1 experienced a fall while being cared for by Nursing Assistant (NA) #1 on 3/4/24. The resident rolled off the bed, sustaining a closed fracture of the left distal femur and a small skin tear to the left elbow. The incident occurred when NA #1 left Resident #1 positioned on his right side with the bed at waist height to retrieve a washcloth, failing to provide the required level of supervision to prevent accidents. The report highlights that Resident #1's care plan clearly indicated the need for two-person assistance with ADL care, which was initiated on 11/01/22 due to the resident's condition and risk factors. Despite this, NA #1 proceeded to provide care independently on the day of the incident, citing a busy environment and familiarity with the resident as reasons for not seeking assistance. Interviews with NA #1, other nursing staff, and the Unit Manager Nurse revealed that Resident #1 was known to require extensive assistance and was considered a two-person assist due to his size and mobility limitations. The subsequent investigations and interviews with medical staff, including the Nurse Practitioner and Medical Doctor, shed light on the series of events following the fall, including subsequent hospital visits for chest pain, facial droop, and acute chest pain, ultimately leading to the resident's transfer to an inpatient hospice facility and eventual passing due to complications from the femur fracture.
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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