Stokes County Nursing Home
Inspection history, citations, penalties and survey trends for this long-term care facility in Danbury, North Carolina.
- Location
- 1570 Nc 8 And 89 Highway, Danbury, North Carolina 27016
- CMS Provider Number
- 345166
- Inspections on file
- 15
- Latest survey
- November 21, 2025
- Citations (last 12 mo.)
- 7
Citation history
Health deficiencies cited at Stokes County Nursing Home during CMS and state inspections, most recent first.
Surveyors found that the facility’s 2025 facility-wide assessment did not include a written contingency plan, informed by the assessment, to address nursing staff and other resource availability during non-emergency events that could affect resident care, potentially impacting all 38 residents. The Assistant Administrator reported being unaware that such a contingency plan was required in the assessment, and the DON confirmed there was no written plan outlining actions for events that could interrupt resident care. The Administrator stated the assessment was reviewed annually but acknowledged that the contingency plan was not included, despite ongoing management turnover.
The facility failed to complete required Abnormal Involuntary Movement Scale (AIMS) assessments for multiple residents receiving antipsychotic medications. One resident on nightly olanzapine had only a single AIMS documented despite a care plan intervention calling for AIMS testing per protocol. Another resident on daily olanzapine, who was severely cognitively impaired and received antipsychotics per the MDS, had no AIMS assessments and no care plan intervention addressing AIMS. A third resident on scheduled quetiapine with documented behavioral symptoms and a prior GDR also had no AIMS assessments and no care plan focus on antipsychotic use. Interviews with the DON, consultant pharmacist, medical director, physician, and administrator showed they were unaware of AIMS frequency requirements, believed AIMS might be captured in the MDS or EMR, and lacked a tracking process, leading to missed and overdue AIMS assessments.
A resident with dementia, anxiety disorder with psychotic features, and recurrent major depressive disorder was readmitted and later restarted on routine Quetiapine for anxiety and depression, as documented in physician orders, the MAR, and MDS assessments. Despite ongoing administration of the antipsychotic and documented behavioral observations, the comprehensive care plan did not include any plan addressing antipsychotic use. The DON was unaware of the omission, the MDS coordinator reported she was in training and not creating care plans, and the Administrator, who was assisting with care plans, acknowledged the care plan was not updated after the antipsychotic was resumed following the resident’s hospital discharge and readmission.
Surveyors found that the facility did not post oxygen-in-use safety signage for three residents who were receiving continuous or ordered oxygen therapy via nasal cannula at 2 lpm for conditions including Streptococcus pyogenes and COPD, despite documentation and repeated observations confirming active oxygen use. Staff interviews revealed that a NA and a nurse had not seen oxygen-in-use signs in the facility and relied on shift report to know which residents were on oxygen. The DON and Administrator stated that, because the campus was smoke free and no smoking signs were posted, they believed there was no need to place oxygen precaution signs on residents’ doors.
The facility failed to ensure the Pharmacy Consultant identified and reported missing Abnormal Involuntary Movement Scale (AIMS) assessments during monthly drug regimen reviews for two residents receiving antipsychotic medications. One resident with dementia, anxiety, psychotic features, and a history of cerebral infarction was prescribed Quetiapine, but had no AIMS assessment on file, and multiple monthly reviews did not note this omission. Another resident with dementia with behaviors and generalized anxiety disorder was prescribed Olanzapine and had only one AIMS assessment documented over an extended period, with subsequent monthly reviews failing to address the need for additional assessments. The Pharmacy Consultant reported she did not believe AIMS assessments were still required and rarely looked for them, while the DON, Medical Director, Facility Physician, and Administrator all stated they were unaware that complete medical record reviews, including verification of AIMS assessments, were not being performed.
A deficiency occurred when a cognitively intact, independent resident with an above-the-knee amputation did not have an accessible bathroom call light because the pull cord was missing on repeated observations. The resident confirmed the absence of the pull cord and noted that if he were on the floor, he could not use the call system. CNAs and an OT reported the resident was independent with ADLs except for showers. The Maintenance Director stated he was unaware of the issue and that no work order had been entered in the engineering book, which review confirmed. The Environmental Service Manager’s weekly room checklist did not address call lights or pull cords, and she did not notice the missing cord during rounds. The DON and Administrator were also unaware of the missing pull cord and relied on staff to report such issues to maintenance.
The facility failed to accurately complete and post daily nurse staffing information for an extended period, leaving RN/LPN designations blank for all listed nurses and omitting shift-specific census information on multiple days and shifts. A nurse reported she only recorded census for the night shift and was unaware that RN/LPN status had to be documented next to each nurse’s name. The DON was unclear about the required census detail and whether RN/LPN designation was mandated, while the Administrator stated that orientation training should cover full completion of the form, including census and licensure designation, yet the forms continued to be filled out incorrectly.
The facility did not submit the required PBJ staffing data to CMS for the third quarter of FY 2023 on time. The Administrator, responsible for the submission, acknowledged the delay, attributing it to staff changes, which resulted in the data being submitted one day late.
The facility lacked a documented water management program for Legionella, potentially affecting all residents. The Infection Preventionist was unsure about the program's existence, and the Maintenance Director lacked knowledge in water management. The Administrator admitted that a written program should have been in place.
Failure to Include Staffing and Resource Contingency Plan in Facility Assessment
Penalty
Summary
The deficiency involves the facility’s failure to ensure that its facility-wide assessment included a written contingency plan, informed by that assessment, to address the availability of nursing staff and other resources during events that did not require activation of the formal emergency plan but had the potential to affect resident care. Record review of the 2025 facility assessment showed that it did not identify or contain such a contingency plan for staffing and resources for non-emergency events. This omission had the potential to affect all 38 residents in the facility. During interviews, the Assistant Administrator stated she was unaware that a contingency plan for staffing and resources for non-emergency events needed to be addressed in the facility assessment and was uncertain why it had not been completed. The DON confirmed there was no written plan specifying what to do when the facility experienced an event that could affect resident care and did not know why such a plan was not in place. The Administrator reported that the facility assessment was reviewed and revised annually but acknowledged that the written contingency plan informed by the assessment was not included, noting that management turnover beginning in 2025 had been complex, while recognizing the facility still had the responsibility to meet the facility assessment requirements.
Failure to Perform Required AIMS Assessments for Residents on Antipsychotic Medications
Penalty
Summary
The deficiency involves the facility’s failure to conduct ongoing Abnormal Involuntary Movement Scale (AIMS) assessments for residents receiving antipsychotic medications. For one resident with dementia with behaviors and generalized anxiety disorder, the physician ordered nightly olanzapine 2.5 mg, and the active care plan identified a risk for complications related to psychotropic and antipsychotic medications with an intervention specifying AIMS testing per protocol. However, the medical record contained only a single AIMS assessment dated 3/10/25, with no additional AIMS assessments found. Another resident, admitted with unspecified dementia without behavior, psychotic disturbance, mood disturbance, and anxiety, had a physician order for daily olanzapine 5 mg. The active care plan for this resident included interventions to monitor and document side effects and effectiveness of olanzapine but did not include any intervention for completing an AIMS assessment. The quarterly MDS documented that this resident was severely cognitively impaired and received antipsychotic medications, yet review of the medical record revealed no AIMS assessments had been completed. A third resident, readmitted with diagnoses including unspecified dementia with behavioral disturbance, anxiety disorder with delusional thoughts and harmful behaviors, major depressive disorder with paranoia and restlessness, and a history of cerebral infarction, had an active care plan after readmission that did not address antipsychotic medication. A subsequent physician order prescribed quetiapine 50 mg in the morning and 100 mg at bedtime for anxiety disorder and recurrent major depressive disorder. The quarterly MDS showed this resident was cognitively intact, had verbal behaviors toward others on some days, and routinely received antipsychotic and antidepressant medications, with the last GDR documented on 5/19/25. Despite this, there were no AIMS assessments in the medical record. Interviews with the DON, consultant pharmacist, medical director, facility physician, and administrator revealed a lack of awareness of AIMS requirements, absence of a process to track when AIMS were due, and system and staffing changes that contributed to AIMS assessments not being completed as needed.
Failure to Update Care Plan for Antipsychotic Medication Use
Penalty
Summary
The deficiency involves the facility’s failure to revise a comprehensive care plan to address the use of an antipsychotic medication for one resident. The resident was readmitted with diagnoses including dementia with behavioral disturbance, anxiety disorder, anxiety with psychotic features, and recurrent unspecified major depressive disorder. A review of the active comprehensive care plan dated 6/10/25 showed no care plan addressing antipsychotic medication use. Physician orders dated 6/29/25 directed administration of Quetiapine Fumarate 50 mg by mouth in the morning and 100 mg at bedtime for unspecified anxiety disorder and unspecified recurrent major depressive disorder, and the MAR from June through November 2025 confirmed the medication was administered as ordered with observations for side effects and behaviors three times daily. Quarterly MDS assessments documented that the resident was cognitively intact, had verbal behaviors toward others on some days during one look-back period, and was routinely receiving antipsychotic medications. Interviews with facility staff further clarified the circumstances leading to the deficiency. The DON stated she was unaware that the resident’s care plan did not include an antipsychotic medication plan but acknowledged that one should have been in place, and reported that the MDS coordinator or Administrator created and updated care plans. The MDS coordinator reported she was in training and not responsible for creating care plans, stating that the Administrator was responsible for initiating and updating them. The Administrator acknowledged that the resident’s care plan did not include an antipsychotic medication care plan and explained that the previous MDS coordinator had created care plans, and that she had assisted with creating and updating them during the new MDS coordinator’s training. She stated the care plan was missing because the resident had been discharged to the hospital and readmitted without an antipsychotic order, and when behaviors later emerged and the antipsychotic was restarted on 6/29/25, the care plan was not updated to reflect the resumed antipsychotic therapy.
Failure to Post Oxygen-In-Use Safety Signage for Residents on Oxygen Therapy
Penalty
Summary
The facility failed to provide appropriate respiratory care by not posting cautionary and safety signage indicating oxygen use for three residents receiving oxygen therapy. One resident with Streptococcus pyogenes had a physician order for continuous oxygen via nasal cannula at 2 liters per minute (lpm) to maintain oxygen saturation above 90%, and the resident’s MDS documented oxygen use. Multiple observations over several days showed this resident in bed with oxygen at 2 lpm and no cautionary or safety signage posted at the room. Another resident with chronic obstructive pulmonary disease (COPD) had a physician order for oxygen at 2 lpm via nasal cannula, and observations on several occasions found the resident in the room using oxygen without any oxygen-in-use signage posted. A third resident with COPD had physician orders for continuous oxygen via nasal cannula at 2 lpm to keep oxygen saturation above 90%, and the MDS also documented oxygen use. Observations on multiple dates and times showed this resident in bed receiving oxygen at 2 lpm with no cautionary or safety signage at the room. During interviews, a nurse aide stated she did not recall ever seeing oxygen-in-use signs on residents’ doors and learned which residents were on oxygen only during shift report, and a nurse reported not seeing any oxygen-in-use signs posted in the facility. The DON stated that precaution signs for oxygen were not needed because the facility was smoke free, and the Administrator similarly stated that with no smoking signs posted throughout the campus and being a smoke-free facility, there was no need for oxygen cautionary signs on residents’ doors.
Failure of Pharmacy Consultant to Identify Missing AIMS Assessments During Monthly Drug Regimen Reviews
Penalty
Summary
The deficiency involves the facility’s Pharmacy Consultant failing to identify and report irregularities related to required Abnormal Involuntary Movement Scale (AIMS) assessments during monthly drug regimen reviews for residents receiving antipsychotic medications. One resident was readmitted with diagnoses including unspecified dementia with behavioral disturbance, anxiety disorder with delusional thoughts and harmful behaviors, recurrent major depressive disorder, paranoia, restlessness, and a history of cerebral infarction. This resident had physician orders for Quetiapine Fumarate, an antipsychotic, but the medical record contained no AIMS assessment. Despite this, multiple monthly drug regimen reviews by the Pharmacy Consultant over several months did not document any need for an AIMS assessment. Another resident was readmitted with dementia with behaviors and generalized anxiety disorder and had an order for Olanzapine, an antipsychotic, with only one AIMS assessment on file since the last recertification survey. Subsequent monthly drug regimen reviews for this resident also lacked any notation that additional AIMS assessments were needed. Interviews further clarified the inactions contributing to the deficiency. The Pharmacy Consultant stated she did not think AIMS assessments still needed to be completed for residents on antipsychotic medications and reported that she rarely reviewed AIMS assessments unless staff reported possible side effects, adding that she had not seen AIMS forms in residents’ records. The DON reported being unaware whether the Pharmacy Consultant reviewed medical records for AIMS assessments and indicated that the Administrator reviewed the Pharmacy Consultant’s reports monthly. The Medical Director and Facility Physician both stated they were not aware that the Pharmacy Consultant was not performing complete medical record reviews that would include checking for AIMS assessments, and the Facility Physician stated he would expect a full medical record review each month. The Administrator reported she was unaware that AIMS assessments were not being reviewed and expected the Pharmacy Consultant to identify and report irregularities, including the need for AIMS assessments, during monthly drug regimen reviews, but did not realize this was not occurring when reviewing the monthly reports.
Failure to Maintain Accessible Bathroom Call Light for Independent Resident
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a working and accessible call light system was available in a resident's bathroom and bathing area. The resident involved had an above-the-knee amputation of the left leg and was assessed as cognitively intact and independent with transfers, bed mobility, toileting, and other ADLs. On multiple observations over three consecutive days, the bathroom call light for this resident was found without an attached pull cord. The resident confirmed that there was no pull cord in the bathroom, could not recall when it was last present, and stated that if he were lying on the floor, he would be unable to use the call light for assistance. Staff interviews showed that nursing assistants and the occupational therapist considered the resident independent in daily care tasks, with assistance only needed for showers. The Facility Maintenance Director reported having a preventative maintenance program but stated it had not been completed and that he was unaware of the missing pull cord because no one had notified him or entered a request in the engineering book. Review of the engineering book showed no service request for the missing pull cord during the specified period. The Environmental Service Manager used a weekly checklist that did not include call lights or pull cords and did not notice the missing pull cord during her room rounds. The DON and Administrator both stated they were unaware of the missing pull cord and indicated that staff were expected to communicate such issues to maintenance via the engineering book or direct calls, but this did not occur in this case.
Failure to Accurately Complete and Post Daily Nurse Staffing Information
Penalty
Summary
The deficiency involves the facility’s failure to post accurate daily nurse staffing information for all 30 days reviewed. Record review of daily nurse staffing sheets showed that the RN/LPN designation was not indicated for the assigned nurses on any of the forms. In addition, the resident census was left blank for both the morning (7:00 AM–3:00 PM) and evening (3:00 PM–11:00 PM) shifts on multiple dates, and was also left blank for the evening shift on several other dates. These omissions meant that the posted staffing forms did not contain complete information on nurse licensure level or shift-specific census as required. During interviews, a nurse reported she had been trained during orientation by an LPN preceptor and knew all areas of the form needed to be completed, but she only documented the census for the 11:00 PM–7:00 AM shift because the number could change on other shifts, and she was not aware that RN or LPN designation needed to be listed beside each nurse’s name. The DON stated she was unsure how training on the daily staffing report was completed, believed the census was per day rather than per shift, and did not know whether listing RN/LPN designation was a state requirement or a facility process. The Administrator stated that nurses received training during orientation, that all areas of the report including census should be completed, and that each nurse’s RN or LPN designation should be listed, but acknowledged the reports were being completed incorrectly.
Failure to Submit PBJ Staffing Data on Time
Penalty
Summary
The facility failed to electronically submit direct care staffing information based on payroll data to the Centers for Medicare and Medicaid Services (CMS) for the third quarter of fiscal year 2023, covering the period from April 1 to June 30, 2023. This deficiency was identified during a review of the Payroll Based Journal (PBJ) Staffing Data report from the Certification and Survey Provider Enhanced Reports (CASPER) database, which revealed that the required data was not submitted. An interview with the Administrator confirmed that she was responsible for submitting the PBJ data and acknowledged that the submission was late due to staff changes, resulting in the data being submitted one day after the deadline.
Lack of Legionella Water Management Program
Penalty
Summary
The facility failed to have a documented water management program for Legionella, which had the potential to affect all 34 residents. A review of the facility's Emergency Preparedness Plan and Infection Control policies showed no evidence of such a program. During an interview, the Infection Preventionist (IP) was unsure about the existence of a written water management program for Legionella. The Administrator indicated that the IP was responsible for overseeing water management, but the Maintenance Director lacked knowledge in this area. The Administrator acknowledged that there should have been a written Legionella water management program in place.
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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