Smoky Mountain Health And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Waynesville, North Carolina.
- Location
- 1349 Crabtree Road, Waynesville, North Carolina 28785
- CMS Provider Number
- 345396
- Inspections on file
- 19
- Latest survey
- March 19, 2026
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Smoky Mountain Health And Rehabilitation Center during CMS and state inspections, most recent first.
Surveyors found unsanitary conditions and improper food storage in the dietary areas, including a walk-in refrigerator with debris and buildup on the floor and shelving that had not been cleaned for an extended period, as well as a dry storage area containing expired thickened liquids and multiple cases of bottled water stored directly on the floor. The Dietary Manager acknowledged responsibility for stocking food and reported that the expired items were overlooked and the water had been placed on the floor during a prior water line break. The Administrator confirmed that established kitchen cleaning protocols and storage standards, including discarding expired food and keeping water off the floor, were not followed.
A resident with anxiety disorder, who was cognitively intact and receiving antianxiety medications, had a PRN Clonazepam order entered into the EMR without the required 14‑day stop date. The PRN psychotropic order remained active and was administered at least once, while multiple staff, including the nurse who entered the order, the unit manager, the DON, and the Medical Director, were unable to clearly identify how the order was initiated or why it lacked a stop date. Although new medication orders were reportedly reviewed in daily morning meetings, this PRN Clonazepam order without a stop date was not identified or corrected through that process.
The facility failed to clearly explain its binding arbitration agreement and to ensure residents and responsible parties understood that signing was optional and not a condition of admission or services. The arbitration form contained only a single signature line and was routinely stamped "accept" without a distinct option to accept or decline arbitration. A cognitively intact resident reported signing admission documents but not agreeing to binding arbitration. Another resident’s responsible party, who received the form by email in very small font, did not recall any verbal explanation, believed the document simply needed to be signed and returned with other admission papers, and stated there was no way to accept or decline arbitration and no intent to agree to binding arbitration. A third resident with moderate cognitive impairment stated he did not know he did not have to sign, nor that signing placed him into a binding arbitration agreement, and he did not want to agree to it. The Admissions Coordinator stated she was trained to have all residents sign the arbitration form on an electronic tablet and stamp it "accept" to show it had been read and explained, and the form did not clarify that this stamp reflected acknowledgment rather than agreement.
The facility failed to complete comprehensive Care Area Assessments (CAAs) for two residents, leading to deficiencies in addressing triggered care areas. One resident had 10 care areas triggered, but analysis was missing for 9 areas, while another resident had 8 areas triggered with no analysis provided. The MDS Coordinator acknowledged the error, and the Director of Nursing emphasized the need for comprehensive CAAs.
A facility failed to complete a PASRR application for a resident with a new psychiatric diagnosis of hallucinations. The resident, admitted with polyosteoarthritis and generalized anxiety disorder, was later diagnosed with hallucinations, but no new PASRR application was completed. Staff interviews revealed confusion over responsibility for PASRR submissions, with the Social Worker untrained and the Business Office Manager unsure of the process.
A facility failed to post cautionary signage outside a resident's room indicating the use of oxygen, despite the resident having a physician's order for continuous oxygen administration due to acute respiratory failure with hypoxia. Observations confirmed the absence of signage, and staff interviews revealed a lack of awareness and responsibility for ensuring the signage was in place.
A facility failed to manage medications properly, with an opened bottle of Latanoprost eye drops lacking an opening date and an expired bottle of docusate sodium liquid found in a medication cart. The LPN acknowledged the oversight, and both the DON and Administrator expected adherence to medication management protocols, highlighting a gap between policy and practice.
Unsanitary Food Storage and Expired Products in Dietary Areas
Penalty
Summary
Surveyors identified a deficiency in the facility’s food service operations related to storage and sanitation in the walk-in refrigerator and dry food storage area. During an observation of the walk-in refrigerator with the Dietary Manager, the floor under the food storage racks was found to have a buildup of grey-white debris that crumbled when touched, and several areas of the floor were raised, white, and fuzzy in appearance. The food storage racks themselves had a thick, grey, sticky substance on the metal shelving. The Dietary Manager stated that the food storage racks were last cleaned in January of the current year and reported that the walk-in refrigerator floor was scheduled to be replaced and, for that reason, had not been cleaned. In the dry food storage area, surveyors observed two unopened cartons of thickened liquid on a storage rack shelf with a use-by date that had already passed, as well as five cases of bottled water stored directly on the floor beneath the racks. The Dietary Manager stated she was responsible for putting away food stock upon delivery and acknowledged that the expired thickened liquid had been overlooked. She also explained that the bottled water had been placed on the floor approximately three weeks earlier during a facility water line break. The Administrator later stated that kitchen cleaning protocols, including those for the walk-in refrigerator, should have been followed, and that water should not be stored on the floor and expired food should be discarded.
Failure to Apply 14-Day Stop Date to PRN Psychotropic Medication Order
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a PRN psychotropic medication, Clonazepam, had a required 14‑day stop date for a resident with an anxiety disorder. The resident was cognitively intact and had documented use of antianxiety medications. Her care plan identified the use of psychotropic medications with potential adverse effects and included an intervention to administer medications per physician orders. A physician order dated 2/19/26 for PRN Clonazepam, one tablet by mouth every 24 hours as needed for anxiety, was entered into the electronic medical record by a nurse without a stop date. Review of the MAR showed that this PRN Clonazepam order remained active beyond initiation and that the resident received at least one PRN dose on 2/19/26. Interviews revealed uncertainty among staff and the Medical Director about how the PRN Clonazepam order was initiated and why it lacked a 14‑day stop date. The resident reported having both a scheduled bedtime dose and a PRN dose of Clonazepam, which she believed she could receive every 12 hours and stated she had this PRN order for a long time. The nurse who administered the PRN dose could not recall how the order was obtained. The Unit Manager stated she was not present when the order was started and did not remember checking it, but acknowledged that PRN psychotropic medications should only be ordered for 14 days. The Medical Director stated he did not see the resident on the date the order was started, did not know how the order was initiated, and confirmed that PRN psychotropic medications should have a 14‑day stop date. The DON and Administrator both indicated that new medication orders were typically reviewed in morning meetings, but this PRN Clonazepam order without a stop date was missed in that process.
Failure to Clearly Explain and Obtain Informed Choice on Binding Arbitration Agreements
Penalty
Summary
The deficiency involves the facility’s failure to clearly explain its binding arbitration agreement and to ensure residents and their responsible parties understood that signing was optional and not a condition of admission or services. The arbitration document stated that it was not a precondition to admission and could be rescinded within 30 days, but the form only provided a single signature line for the resident or responsible party, with no clear way to indicate acceptance or declination of arbitration. For one cognitively intact resident, the arbitration agreement was signed and stamped “accept,” yet the resident later stated that although he understood the general meaning of arbitration, he did not agree to binding arbitration when he signed the admission documents. Another resident with severe cognitive impairment had an arbitration agreement signed by a responsible party, which was also stamped “accept.” The responsible party reported receiving the agreement by email with very small font, did not recall any person explaining it, and believed there was only an option to sign and return it with other admission documents, with no way to accept or decline arbitration; he stated he did not intend to agree to binding arbitration. A third resident with moderate cognitive impairment signed an arbitration agreement that was stamped “accept” and later reported not knowing that signing was optional or that it placed him into a binding arbitration agreement, and stated he did not want to agree to binding arbitration. The Admissions Coordinator reported that all arbitration agreements were completed electronically on a tablet as part of the admission packet, that she was trained to have all residents sign the arbitration form and stamp it “accept” to show it had been read and explained, and that the form did not specify that the “accept” stamp was only to acknowledge explanation rather than agreement to binding arbitration.
Incomplete Care Area Assessments for Two Residents
Penalty
Summary
The facility failed to complete the Care Area Assessment (CAA) comprehensively for two residents, leading to deficiencies in addressing the underlying causes and contributing factors of triggered care areas. Resident #10, admitted with diagnoses including non-Alzheimer's dementia, anxiety disorder, and osteoarthritis, had 10 care areas triggered in a significant change in status MDS assessment. However, the MDS Coordinator did not provide any analysis for 9 of these areas, which included delirium, cognitive loss/dementia, and psychotropic drug usage, among others. Similarly, Resident #11, with diagnoses such as diabetes mellitus and non-Alzheimer's dementia, had 8 care areas triggered in an annual MDS assessment, but the facility failed to provide analysis for all these areas, which included cognitive loss/dementia and nutritional status. Interviews with the MDS Coordinator and the Director of Nursing revealed that the assessments were submitted without the necessary comprehensive analysis due to an oversight by the former MDS Coordinator. The current MDS Coordinator, who started in November, acknowledged the error and the Director of Nursing emphasized the expectation for individualized and comprehensive completion of CAAs. The Administrator also confirmed the expectation for adherence to MDS guidelines, ensuring that all CAAs include the nature of problems, causative factors, and reasons to proceed to care planning before submission.
Failure to Complete PASRR for New Psychiatric Diagnosis
Penalty
Summary
The facility failed to complete a Preadmission Screening and Resident Review (PASRR) application for a resident who developed a new psychiatric diagnosis. The resident, admitted on September 2, 2023, with diagnoses including polyosteoarthritis and generalized anxiety disorder, was later diagnosed with hallucinations on August 1, 2024. However, there was no record of a new PASRR application being completed following this diagnosis. The resident's care plan, initiated on April 8, 2024, noted an acute confusional state with behaviors and altered thought processes, but the most recent Minimum Data Set assessment did not reflect the hallucinations. Interviews with facility staff revealed a lack of clarity and responsibility regarding the PASRR process. The Social Worker, who joined the facility in November 2024, was not involved with PASRR and indicated that the Business Office Manager was responsible for obtaining PASRR information. The Business Office Manager, however, was unsure who should submit new PASRR applications for residents with new mental health diagnoses, as the previous Social Worker had handled this task. The Administrator confirmed that the Social Worker was supposed to submit new PASRR applications but had not yet been trained, and acknowledged that a vacancy in the Social Worker position might have contributed to the oversight.
Failure to Post Oxygen Use Signage for Resident
Penalty
Summary
The facility failed to post cautionary and safety signage outside a resident's room to indicate the use of oxygen for a resident who required respiratory care. The resident, who was admitted with acute respiratory failure with hypoxia, had a physician's order for continuous oxygen administration via nasal cannula. Observations on two separate occasions revealed that the resident was receiving oxygen, but there was no signage posted outside the room to indicate the use of supplemental oxygen. Interviews with facility staff, including a nurse and the Director of Nursing (DON), revealed that the responsibility for placing oxygen signage on a resident's door fell to the nurse who completed the admission. However, the nurse was unaware that the signage was missing for this resident. The DON confirmed that the signage should have been in place and was unsure why it was not. The facility administrator also stated that nurses should validate physician orders related to oxygen and ensure signage is posted.
Medication Management Deficiency: Expired and Undated Medications Found
Penalty
Summary
The facility failed to adhere to proper medication management protocols, resulting in the presence of expired and improperly labeled medications. During an observation of Medication Cart #1, it was found that an opened bottle of Latanoprost eye drops, used for treating glaucoma, was stored at room temperature without an opening date. The manufacturer's guidelines specify that once opened, Latanoprost should be stored at room temperature for no more than six weeks, and the absence of an opening date made it impossible to determine if this guideline was being followed. Additionally, a bottle of docusate sodium liquid, used to treat constipation, was found to be expired since 01/31/25, yet it remained in the cart with 15 ounces still available for use. Interviews with the nursing staff and administration revealed a lack of compliance with the facility's medication management policies. Nurse #2 acknowledged the oversight, stating that medication carts are supposed to be checked by the third shift nurse every Sunday to ensure proper storage and removal of expired medications. However, the expired docusate solution and the undated Latanoprost eye drops were not identified during these checks. Both the Director of Nursing and the Administrator expressed their expectations that all medications should be dated upon opening and that expired medications should be routinely removed, indicating a gap between policy and practice within the facility.
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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