The Greens At Hickory
Inspection history, citations, penalties and survey trends for this long-term care facility in Hickory, North Carolina.
- Location
- 3031 Tate Boulevard Se, Hickory, North Carolina 28602
- CMS Provider Number
- 345232
- Inspections on file
- 20
- Latest survey
- January 28, 2026
- Citations (last 12 mo.)
- 11
Citation history
Health deficiencies cited at The Greens At Hickory during CMS and state inspections, most recent first.
Surveyors identified that the facility exceeded the acceptable medication error rate when two residents experienced medication administration errors during observed passes. For a resident with diabetes, an insulin pen was used without performing the manufacturer-required priming step before delivering a 20-unit Tresiba dose. In a separate case, a resident ordered to receive one spray of fluticasone furoate in each nostril once daily was instead given two sprays in each nostril. These observed deviations from the physician orders and product instructions resulted in a calculated medication error rate above 5%.
Two residents received medications prescribed for other residents when agency nurses failed to verify the correct recipient during medication passes. In one case, a cognitively intact resident with multiple chronic conditions was given his roommate’s bedtime medications, including metformin, carvedilol, trazodone, melatonin, senna, and tizanidine, after the nurse pulled the wrong MAR and did not follow the five rights of medication administration. In the second case, a cognitively intact resident with ESRD, CAD, HTN, DMII, and COPD was given acetaminophen and buspirone ordered for another resident at a time when he had no scheduled meds, with the error identified only after a family member questioned the unexpected dosing and staff confirmed the wrong-resident administration through MAR review.
A resident with severe cognitive impairment, malnutrition, and feeding difficulty, who required partial/moderate staff assistance with eating, was observed being fed lunch while seated in a wheelchair in a hallway across from the nurse’s station. A Speech Therapist stood beside the resident and provided bites of food throughout the meal, despite empty chairs being available nearby. The ST later stated she did not see any chairs and that the resident was in the hallway due to a flu/COVID-19 outbreak, although the resident normally ate in the dining room. The DON and Administrator both reported they expected staff to be seated and to feed residents in a respectful manner, and the reasonable person concept was applied to determine that hallway feeding while standing over the resident failed to ensure a dignified dining experience.
A resident with dementia, diabetes, COPD, and bilateral hand contractures had orders and care plan interventions for weekly head-to-toe skin assessments, use of bilateral palm guards, and monitoring of skin and contracture-related complications. Despite this, nursing and MDS staff did not remove hand splints or palm guards during assessments and documented that nails were trimmed and no new skin issues were present, while surveyors later observed long fingernails and a reddened area on the right palm matching the middle fingernail, which had previously pressed into the contracted hand. The resident reported disliking long nails because they dug into his skin, and staff acknowledged foul odor and moist exudate in the right hand but had not identified or reported the reddened area or notified the wound nurse, resulting in the skin issue remaining unassessed and untreated.
The facility failed to ensure meals were palatable, attractive, and served at appetizing temperatures, as multiple cognitively intact residents reported undercooked or overcooked items, excess liquid on plates, bland or poorly seasoned food, and meals that were often cool or cold by the time they arrived, especially to rooms at the end of hallways. A grievance had been filed about liquids from vegetables saturating other foods, and residents described burnt toast, runny mashed potatoes, and trays that looked unappetizing. Test trays showed that, although food left the kitchen above required holding temperatures, by the time trays reached the halls the items were only warm, lacked visible steam, included mushy or pale components, and had liquids bleeding between foods, confirming concerns about both temperature control and food quality.
A resident received another resident's medications in error, and although a Change in Condition form was completed by the DON with vital signs, allergies, and notification details, neither the nurse who made the error nor the supervising nurse documented which specific medications were administered. As a result, the medical record lacked any entry identifying the medications given in error, leaving the record incomplete and inaccurate regarding the medication incident.
The facility failed to obtain and document informed consent, including discussion of risks and benefits, before initiating and escalating the psychotropic medication divalproex sodium for three severely cognitively impaired residents with dementia and related psychiatric diagnoses. A psychiatric NP recommended divalproex for behaviors such as aggression, agitation, hallucinations, and evening agitation, and physicians ordered progressive dose increases that were administered as recorded on the MAR. However, the medical records for each resident contained no evidence that a representative had been informed in advance of the risks versus benefits or had consented, and both the unit manager and DON acknowledged in interviews that psychotropic consents were their responsibility and had been overlooked, despite the administrator’s stated expectation that such consents be obtained prior to starting or changing psychotropic medications.
The facility failed to maintain accurate and consistent advance directive documentation for two residents. For one cognitively intact resident, a physician’s DNR order and a DNR form in the advance directive binder were not reflected in the care plan, which continued to list the resident as full code with interventions for full resuscitation. For another resident with severe cognitive impairment, physician orders, the care plan, and the EMR banner all showed DNR status, but the DNR form was missing from the advanced directives notebook used by staff for rapid code-status verification, reportedly due to the form not returning after a hospital transfer and not being replaced or detected during routine checks.
A resident with newly documented diagnoses of PTSD and major depressive disorder, along with recent suicidal ideations and ongoing psychiatric treatment with an antidepressant, did not have a Level II PASRR evaluation requested or documented. Although the resident’s care plan and psychiatric notes reflected active serious mental health conditions and targeted interventions, the SW did not initiate a Level II PASRR because no new behaviors were observed, and the facility was unable to produce any evidence that a Level II PASRR request had ever been submitted.
Surveyors found that the facility did not follow physician and RD orders for double portions/double protein portions for two residents. One resident with hypothyroidism and prior unintentional weight loss had an order and care plan for a regular diet with double portions, but during an observed lunch received only a standard serving of chicken despite a tray card specifying double portions; the resident reported rarely receiving the ordered double portions, and dietary staff confirmed the plate did not meet the double-protein standard. Another resident with diabetes, adult failure to thrive, multiple comorbidities, and end-of-life skin failure had an order for a mechanical soft diet with double protein portions, yet an observed chicken salad sandwich was plated as a thin, standard sandwich rather than with the required double meat, which the RD and Dietary Manager later confirmed did not meet the ordered double protein portion.
Surveyors found that wheelchairs and geri chairs used by three residents were repeatedly observed over several days with dried white and yellow-brown substances on armrests, frames, and padding, as well as hair or string-like debris wrapped around wheels, without improvement. The Environmental Services Director stated that such equipment was cleaned monthly and as needed, with the last cleaning having occurred weeks earlier, and noted that housekeeping had not been notified by nursing staff that these specific chairs required additional cleaning. The Administrator reported he expected equipment to be kept clean and for nursing staff to alert housekeeping when more frequent cleaning was necessary.
Expired medications and IV fluids were found in three medication storage rooms of a facility. The ADON and Unit Manager, responsible for checking for expired items, failed to identify numerous expired syringes of Heparin and bags of Normal Saline. The DON confirmed that the facility did not follow its medication storage process.
The facility failed to accurately code MDS assessments for two residents, leading to deficiencies in opioid medication and bowel continence documentation. One resident was not coded for opioid use despite receiving medication, and another was inaccurately coded for bowel continence despite documented incontinence. Errors were attributed to mis-clicks by MDS nurses, as confirmed by interviews with nursing staff.
A resident with COPD was found to be receiving oxygen at 4 liters per minute instead of the prescribed 2 liters. Observations revealed that nursing staff failed to check the oxygen concentrator settings as required. The resident, with moderately impaired cognition, was unaware of the correct setting and unable to adjust it. The DON acknowledged the oversight and the need for more frequent monitoring.
A facility did not follow a pharmacy recommendation to monitor side effects and behaviors for a resident on antipsychotic medication. Despite being aware of the recommendation, the DON acknowledged it was overlooked, and the Consultant Pharmacist's follow-up was delayed due to a hurricane.
A resident with schizophrenia was prescribed risperidone, but the facility failed to monitor for side effects and behaviors as recommended by the Consultant Pharmacist. Despite the pharmacist's suggestion in August, the MARs lacked monitoring instructions from July to November. Staff interviews revealed that the responsibility for adding these instructions was not fulfilled, with the DON and a nurse acknowledging the oversight.
Two nurse aides failed to follow infection control protocols during incontinence care for a resident with a stage IV sacral wound. One aide did not sanitize her hands after removing soiled gloves, while the other improperly handled soiled linen by throwing it on the floor. Both aides had recently received training on infection control.
Medication Administration Errors Result in Exceeded Medication Error Rate
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with surveyors identifying 2 errors out of 28 medication administration opportunities, resulting in a 7.14% error rate. For one resident with diabetes mellitus, a physician order dated 12/06/25 directed administration of 20 units of Tresiba insulin via prefilled pen injector once daily subcutaneously. Manufacturer instructions for the Tresiba pen specified that the pen must be primed with 2 units before each dose by dialing to 2 units, holding the pen with the needle up, tapping gently, and pressing the button until the counter returned to 0 and a drop of insulin appeared. During an observation on 01/22/26, Nurse #5 removed the Tresiba pen from the medication cart, dialed the dose directly to 20 units, and administered the insulin without priming the pen as required by the manufacturer’s instructions. In a subsequent interview, the nurse stated she followed the five rights of medication administration and acknowledged she knew the pen should have been primed and believed she had primed it before giving the dose. In a separate incident, another resident had a physician order dated 01/13/26 for fluticasone furoate nasal spray, one spray in both nostrils once daily for sinus/allergies. On 01/22/26, during observed medication administration, Nurse #7 prepared and administered the nasal spray and was seen giving two sprays in each nostril instead of the ordered one spray in each nostril. In a later interview, the nurse recounted administering two sprays in each nostril, then reviewed the order, which specified one spray in each nostril, and stated she should have read the order more carefully. These two observed deviations from physician orders and manufacturer instructions during medication administration contributed to the facility’s medication error rate exceeding the 5% threshold.
Medication Administration Errors Involving Wrong-Resident Dosing
Penalty
Summary
The deficiency involves the facility’s failure to ensure medications were administered according to physician orders, resulting in residents receiving medications prescribed for other residents. In the first incident, a cognitively intact resident with diagnoses including diabetes mellitus, hypertension, constipation, restless leg syndrome, hallucinations, and major depressive disorder was given his roommate’s medications during a bedtime medication pass. The medications administered in error included melatonin, sennosides, tizanidine, trazodone, carvedilol, and metformin, all of which were ordered for the roommate. The error occurred when the nurse assigned to both residents’ section pulled the roommate’s medications and mistakenly administered them to the wrong resident. The circumstances leading to this first error included the nurse’s failure to follow basic medication administration protocols. The DON later explained that the agency nurse did not check the five rights of medication administration before giving the medications. The resident was his own responsible party and was informed of the error, and the on-call provider was notified. The Medical Director later stated that the roommate was not on anything that could harm the resident and that the resident was prescribed some of the same medications he received in error. However, the deficiency centers on the nurse’s incorrect selection and administration of medications intended for another resident during the medication pass. In the second incident, another cognitively intact resident with diagnoses including end stage renal disease on dialysis, coronary artery disease, hypertension, diabetes mellitus type II, and COPD received medications that were not prescribed for him during a 2:00 PM medication pass. This resident had no medications ordered at that time, but was given acetaminophen 325 mg (three tablets) and buspirone 7.5 mg (one tablet), which were ordered for a different resident with spastic hemiplegia following stroke, diabetes mellitus type II, and chronic pain syndrome. The error was discovered when the resident’s family member questioned the administration of medications at a time the resident did not usually receive them. Review of the MARs by facility staff confirmed that the agency nurse had administered another resident’s scheduled 2:00 PM medications to this resident, constituting a second medication administration error arising from failure to ensure that medications were given only to the residents for whom they were prescribed.
Failure to Provide Dignified Dining Assistance in Hallway
Penalty
Summary
The deficiency involves the facility’s failure to provide a dignified dining experience for a dependent resident when a Speech Therapist (ST) assisted with a meal while standing in a hallway. The resident, admitted with diagnoses including malnutrition and feeding difficulty, had a significant change MDS showing severe cognitive impairment and a need for partial/moderate staff assistance with eating. During a continuous observation of a lunch meal, the resident was seated in a wheelchair in the hall directly across from the nurse’s station with his meal tray on an overbed table. The ST stood on the resident’s right side and provided bites of food while three empty chairs were observed behind the nurse’s station. In a subsequent interview, the ST confirmed she fed the resident in the hallway and remained standing the entire time, stating she did not see any available chairs and that the resident usually ate in the dining room but was in the hallway that day due to a flu/COVID-19 outbreak. The DON stated she expected staff to be seated when feeding residents and believed feeding in the hallway was safer than in resident rooms because more staff were available if an emergency occurred. The Administrator stated he expected residents to be fed in a respectful manner and for staff to be seated when feeding residents. The reasonable person concept was applied, as individuals might feel a lack of dignity when assisted with eating in a hallway and when staff stand over them.
Failure to Identify and Treat Hand Skin Breakdown Related to Overgrown Nails and Contractures
Penalty
Summary
The deficiency involves the facility’s failure to complete thorough skin assessments and obtain appropriate treatment orders for a reddened area on a resident’s right palm caused by an overgrown fingernail in the setting of bilateral hand contractures. The resident had diagnoses including COPD, diabetes mellitus, bilateral hand contractures, and dementia, and was severely cognitively impaired, requiring total assistance with all ADLs except eating. Physician orders included a weekly head-to-toe skin assessment on a specific shift and an order for bilateral palm guards with instructions to check skin integrity prior to application. The care plan identified the resident as having an ADL self-care performance deficit and an alteration in musculoskeletal status related to bilateral hand contractures, with interventions that included adaptive equipment, bilateral hand splints, good hygiene, skin monitoring, and notification of the provider for complications. Despite these orders and care plan interventions, multiple assessments and observations failed to identify and address a reddened area on the resident’s right palm caused by his middle fingernail pressing into his palm. A weekly skin assessment documented that the resident’s fingernails were cleaned and trimmed and that there were no new skin abnormalities, even though later observations showed long fingernails extending approximately 1/4 inch beyond the fingertips and an indentation in the right palm matching the middle fingernail. The reddened area on the palm measured approximately 0.2 cm by 0.2 cm by 0.1 cm and appeared to have been open at one time but was no longer open, remaining red in color. Staff, including the MDS coordinator and nurses, reported that they did not remove the resident’s splints or palm guards during assessments and were not aware of any skin issues on his hands. Over several days, surveyor observations documented that the resident’s fingernails remained long, that the middle finger continued to press into the palm, and that there was a malodor and moist exudate previously noted in the right hand by staff. The resident himself stated that he wanted his fingernails trimmed because he did not like them long as they dug into the skin of his hand, and he reported that no one had discussed cutting his fingernails with him. Nurse aides and nursing staff acknowledged noticing foul odor and moist exudate in the right hand at times and cleaning and drying the area, but they had not identified or reported the reddened area caused by the fingernail until it was pointed out during observations. The wound nurse was never notified of any skin issue on the resident’s right hand, and unit management and therapy staff were unaware of the reddened area until the time of the surveyor’s observations and interviews, demonstrating that the ordered and care-planned skin monitoring and assessment processes were not effectively carried out for this resident. Facility leadership, including the DON and Administrator, stated that nurses should have been checking the resident’s hands and palms daily and during weekly skin assessments, removing palm guards to thoroughly observe the skin, and recognizing and reporting new skin issues for treatment and further evaluation. However, the documented assessments and staff interviews show that these actions did not occur, resulting in the reddened area on the resident’s right palm from his middle fingernail pressing into his skin going unrecognized and untreated over time.
Failure to Provide Palatable, Proper-Temperature Meals
Penalty
Summary
The deficiency involves the facility’s failure to provide palatable, attractive meals at safe and appetizing temperatures for multiple cognitively intact residents. One resident had previously filed a grievance about excess liquid saturating meal plates, specifically noting that liquid from vegetables was running into other foods. In subsequent interviews, this resident reported ongoing concerns that food was often undercooked, greasy or watery, toast was burnt, and mashed potatoes were extremely runny, and stated that the quality and presentation of meal trays had not improved despite voicing these concerns. Two additional cognitively intact residents also reported dissatisfaction with the quality and temperature of their meals. One resident stated that meal trays were often cold and lacked good flavor or texture. Another resident described the food quality and temperature as unsatisfactory, saying the trays looked like vomit and that most days the meals arrived cold to his room, which was located at the end of a hall. During a Resident Council group interview, several residents reported issues with food, including lack of seasoning and over- or undercooking of various items. Direct observations of two test trays further demonstrated problems with palatability, appearance, and temperature. Although foods on the service line were initially above 135°F, by the time the test trays were plated, transported, and observed, there was no visible steam, and most items were only warm, not hot. One tray’s yams were mushy and bland, and the other tray’s chicken tenders appeared pale with soft, mushy breading; liquid from the cabbage bled into the chicken and rice, affecting presentation. Residents who received similar meals on that day rated them poorly, describing them as cool, not very appetizing, and with poor appearance. The Dietary Manager acknowledged that the test tray meals were not warm and that delayed tray delivery on the halls, especially to rooms at the end of hallways, could contribute to the temperature issues.
Failure to Document Medications Given in Error in Resident Medical Record
Penalty
Summary
The facility failed to maintain a complete and accurate medical record for a resident who received another resident's medications in error. The resident was admitted on an unspecified date and experienced a medication variation on the night of 11/06/25, when the assigned nurse administered medications intended for a different resident. A Change in Condition form completed by the DON on 11/06/25 documented that a medication variation had occurred, included the resident's vital signs, allergies to penicillin and tuberculin solution, and noted there were no changes in the resident's mental, physical, or behavioral status. The form also documented that the resident, who was his own responsible party, and the on-call physician service were notified, and that the physician ordered monitoring for changes. Despite this, the medical record contained no documentation specifying which medications were given in error. The Change in Condition form did not list the medications administered by mistake, and there was no other documentation in the record identifying them. Supervisor #9 reported that the nurse who made the error had informed her that she had given the resident another resident's medications, but stated she did not document the medications because she believed the responsibility lay with the nurse who made the error. The DON confirmed that neither the nurse nor the supervisor documented the specific medications given in error and acknowledged that this information should have been entered into the medical record at the time of the incident and included on the Change in Condition form.
Failure to Obtain Informed Consent for Psychotropic Medication Initiation
Penalty
Summary
The deficiency involves the facility’s failure to obtain and document informed consent, including discussion of risks and benefits, prior to initiating the psychotropic medication divalproex sodium for three residents reviewed for unnecessary medications. For each of these residents, divalproex sodium was ordered and administered as a psychotropic/anticonvulsant and mood-stabilizing medication without evidence in the medical record that the resident or their representative had been informed in advance of the risks versus benefits or had consented to the treatment. The Medication Administration Records confirmed that the medication was given as ordered over extended periods. One resident was admitted with diagnoses including unspecified dementia, psychotic mood disturbance, anxiety, and depression, and was identified on the MDS as severely cognitively impaired and receiving antianxiety, antidepressant, and antipsychotic medications. A psychiatric NP note documented increased aggressive behavior, hoarding, and visual hallucinations, with a recommendation to start divalproex sodium. Physician orders show a series of dose escalations from 125 mg twice daily to 500 mg twice daily over time for dementia and psychotic mood disorder, yet the medical record contained no documentation that the resident’s representative was informed of the risks and benefits or provided consent before initiation. The unit manager and DON both acknowledged that consent for this psychotropic medication had been overlooked. A second resident, admitted with unspecified dementia, Alzheimer’s disease, bipolar disorder, and delusional disorder, was also severely cognitively impaired per MDS and was receiving antidepressant, anticonvulsant, and antipsychotic medications. A psychiatric NP note described increased irritability, anger, and agitation, and recommended starting divalproex sodium 125 mg daily, which was subsequently titrated up to 500 mg twice daily according to physician orders. The MAR showed the medication was administered as ordered, but there was no documentation that the resident’s representative had been informed in advance of the risks versus benefits or had consented. The unit manager and DON stated that obtaining consent for this psychotropic medication was their responsibility and that it had been overlooked. A third resident, admitted with unspecified dementia, major depressive disorder, hallucinations, and anxiety disorder, had a psychiatric NP note describing increased evening agitation, cursing, and yelling at staff and peers, with a plan to start divalproex sodium 250 mg twice daily for disturbed mood and anxiety. Physician orders documented dose increases up to 500 mg twice daily for dementia and anxiety, and the MAR confirmed ongoing administration. The resident was identified as severely cognitively impaired on the MDS and was receiving antidepressant, anticonvulsant, and antipsychotic medications. The medical record lacked any documentation that the resident’s representative was informed in advance of the risks versus benefits of divalproex sodium or had provided consent. In interviews, the unit manager and DON again stated that consents for this psychotropic medication were not obtained and were overlooked, while the administrator stated he expected informed consents, including discussion of risks and benefits, to be obtained prior to starting or changing psychotropic medications.
Inconsistent Advance Directive Documentation and Missing DNR Forms
Penalty
Summary
The facility failed to maintain accurate and consistent documentation of advance directives across the medical record and related reference tools for two residents. For one cognitively intact resident, the care plan initiated on 04/18/25 documented a full code status with interventions to call 911 and initiate all life-sustaining measures if the resident’s heart or breathing stopped. However, the medical record contained a physician’s order dated 01/12/26 for Do Not Resuscitate (DNR), and a DNR form dated the same day was present in the advance directive binder at the nurse’s station. The MDS Coordinator stated it was the MDS nurse’s responsibility to update care plans when new orders were written and acknowledged that the resident’s care plan should have been revised on 01/13/26 after review of new orders, but this was missed. For another resident with severe cognitive impairment, the physician’s orders and care plan documented a DNR status, and the EMR banner also indicated DNR. The facility maintained an advanced directives notebook at the nurse’s station for quick reference in emergencies, but this resident’s DNR form was not present in the notebook. A nurse reported that in an emergency she would check both the EMR and the notebook, and if no DNR form was in the notebook, she would determine the resident to be full code. The unit manager and DON explained that DNR forms were to be completed on admission, kept in the notebook, and sent with the resident to the hospital, with the receiving nurse responsible for verifying the form’s return and the unit manager responsible for weekly checks. They indicated the resident’s DNR form likely did not return from a recent hospital transfer and had not been replaced or identified as missing, resulting in the absence of the DNR form in the notebook despite an active DNR order.
Failure to Request Level II PASRR After New Serious Mental Health Diagnoses
Penalty
Summary
The deficiency involves the facility’s failure to request a Level II Preadmission Screening and Resident Review (PASRR) evaluation after a resident was given new diagnoses of serious mental health disorders. The resident had a Level I PASRR completed prior to or at admission, and the annual MDS later indicated the resident was not considered by the state Level II PASRR process to have a serious mental illness or intellectual disability. However, the resident’s cumulative diagnoses list showed active diagnoses of Post-Traumatic Stress Disorder (PTSD) and Major Depressive Disorder, recurrent severe without psychotic features, both added after admission. The resident’s care plan documented a possible history of an unknown traumatic event or experience, signs and symptoms of PTSD, and recent suicidal ideations, with interventions focused on meaningful activities, reducing known trauma triggers, and using techniques such as art to reminisce on positive memories. A psychiatric progress note documented ongoing treatment for major depressive disorder and PTSD, with the resident prescribed citalopram and instructions to continue monitoring for symptoms. Despite these documented serious mental health diagnoses and ongoing psychiatric treatment, review of the medical record revealed no Level II PASRR evaluation, and the facility could not provide documentation that a request for such an evaluation had been submitted. In an interview, the social worker stated that when the PTSD diagnosis was added, she reviewed the record, saw no new behaviors, and therefore did not request a Level II PASRR screen, and she could not find any record of a Level II PASRR request. The administrator stated that his expectation was that a Level II PASRR be requested when indicated by a new psychiatric diagnosis.
Failure to Provide Ordered Double Protein Portions for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to follow physician and RD diet orders for double portions or double protein portions for two residents. One resident was admitted with hypothyroidism and a history of unintentional weight loss and had a physician order for a regular diet with double portions for weight management. The RD documented that the resident had a good appetite, usually ate 75–100% of meals, and that adding double portions to all meals helped stabilize the resident’s weight. The care plan directed staff to provide the diet as ordered and monitor intake, and the MDS showed the resident was cognitively intact and had no recent weight gain or loss. During a lunch observation, the resident’s meal ticket indicated a regular diet with double portions, but the tray contained only two chicken tenders, one serving of mashed potatoes, one serving of cabbage, and one dinner roll. The resident reported he was supposed to receive double portions and stated he had only received double portions approximately twice since admission, adding that he could eat four chicken tenders. The Dietary District Manager confirmed that double portions meant two servings of protein and that the resident should have received four chicken tenders. The Dietary Manager and Dietary Aide #1 both acknowledged that, given the physician order for double portions, the resident should have received four chicken tenders and that the aide, who was responsible for checking tray accuracy, had overlooked the missing double portion. A second resident, admitted with diabetes and adult failure to thrive, had a nutrition care plan noting nutritional risk related to multiple comorbidities, abnormal nutrition-related labs, and the need for a texture-modified diet. Interventions included RD evaluation and serving the diet as ordered. The MDS showed moderate cognitive impairment, dependence on staff for eating, a mechanically altered diet, and nutrition/hydration interventions for skin problems. The RD progress note documented a current order for a mechanical soft diet with double protein portions and end-of-life skin failure at multiple sites, and the physician’s order specified a mechanical soft diet with double protein portions. Observation of this resident’s lunch tray showed a chicken salad sandwich, potato salad, chopped broccoli salad, and mandarin oranges; the sandwich appeared uniformly thin with bread edges touching, indicating it did not contain a double protein portion. The RD later stated that double protein meant double meat in sandwiches, and the Dietary Manager explained that double protein portions should be plated using a #8 scoop so that the meat would be visibly thicker and prevent the bread from fully meeting, confirming that the observed sandwich did not meet the ordered double protein portion.
Failure to Maintain Clean and Sanitary Wheelchairs and Geri Chairs
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to maintain sanitary wheelchairs and geriatric chairs for multiple residents. For one resident, repeated observations over several days showed a wheelchair with a dried yellow-brown substance on both armrests, the frame, and all four wheels, with no change in condition between observations. For a second resident, a geriatric chair was observed on multiple occasions with dried white and yellow substances on both armrests, a dried yellow-brown substance on the headrest padding to the left of the resident’s head, and visible strands of hair or string-like debris wrapped around parts of all four wheels, again with no improvement noted over several days. A third resident’s geriatric chair was observed on several different days with a dried white substance on both armrests and visible strands of hair or string-like debris wrapped around parts of all four wheels, with the condition persisting across all observations. In a joint interview, the Environmental Services Director reported that wheelchairs and geriatric chairs were cleaned once a month and as needed by housekeeping staff, and that the last cleaning occurred on 12/11/25. The Environmental Services Director also stated that housekeeping staff had not been notified by nursing staff that these specific chairs needed additional cleaning. The Administrator stated he expected wheelchairs and geriatric chairs to be clean and expected nursing staff to notify housekeeping if more frequent cleaning was needed.
Expired Medications Found in Facility's Storage Rooms
Penalty
Summary
The facility failed to remove expired medications and intravenous fluids from three of its four medication storage rooms, specifically the East, North, and Memory Care units. During observations, numerous expired syringes of Heparin and bags of Normal Saline were found, with expiration dates ranging from February 2022 to September 2024. The Assistant Director of Nursing (ADON) and the Unit Manager were responsible for ensuring that expired medications were not present, with the ADON claiming to have recently audited the medication carts and storage rooms. However, the ADON admitted to never checking the drawers where the expired Heparin was stored. Interviews with the ADON and the Director of Nursing (DON) revealed a lack of adherence to the facility's medication storage process. The ADON stated that she checked medication carts for expired medications and supplies but was uncertain about the thoroughness of her checks in the medication storage rooms. The DON confirmed that the ADON should have been checking for expired medications and supplies at least weekly, indicating a failure in following the established procedures for medication storage and management.
Inaccurate MDS Coding for Opioid Use and Bowel Continence
Penalty
Summary
The facility failed to accurately code Minimum Data Set (MDS) assessments for two residents, leading to deficiencies in the areas of opioid medication and bowel continence. Resident #65, who was admitted with chronic pain, was not coded as taking opioid medications in her quarterly MDS assessment, despite receiving hydrocodone-acetaminophen twice daily during the assessment lookback period. Interviews with the MDS Nurse and Director of Nursing confirmed that the opioid medication should have been accurately coded, but a mis-click was identified as the cause of the error. Similarly, Resident #67, admitted with a fracture of the left femur, was inaccurately coded as 'not rated' for bowel continence in his significant change in status MDS assessment. However, records showed he had 10 bowel movements and was incontinent during the lookback period. The MDS Nurse acknowledged the mistake, attributing it to a mis-click, and the Director of Nursing confirmed that the resident's bowel continence should have been correctly coded. Both cases highlight the facility's failure to ensure accurate MDS assessments, as expected by the Administrator.
Failure to Deliver Oxygen at Prescribed Rate
Penalty
Summary
The facility failed to ensure that supplemental oxygen was delivered at the physician-prescribed rate for a resident with coronary artery disease, heart failure, and chronic obstructive pulmonary disease (COPD). The resident was supposed to receive oxygen at 2 liters per minute, as per the physician's order. However, observations on two consecutive days revealed that the oxygen concentrator was set to deliver 4 liters per minute. The resident, who had moderately impaired cognition and required substantial assistance, was unaware of the correct oxygen setting and could not reach the concentrator to adjust it. Interviews with nursing staff revealed lapses in monitoring the oxygen concentrator settings. Nurse #1, responsible for the resident during the day shifts, admitted to not checking the setting on one of the days. Unit Manager #1 also failed to verify the correct setting, focusing only on the tubing and bag changes. The Director of Nursing acknowledged that nurses were responsible for checking the settings every shift but learned that the resident might have been adjusting the concentrator using a Reacher. The facility had not identified this as a problem or included it in the care plan for more frequent monitoring.
Failure to Implement Pharmacy Recommendations for Antipsychotic Monitoring
Penalty
Summary
The facility failed to implement a pharmacy recommendation for a resident receiving antipsychotic medication. The resident, who was admitted with a diagnosis of schizophrenia, was prescribed risperidone at varying dosages over several months. A pharmacy report dated August 16, 2024, recommended adding side effect and behavior monitoring to the resident's medication regimen. However, reviews of the Medication Administration Records from July to November 2024 showed no such monitoring instructions were added. Interviews with the Consultant Pharmacist, Director of Nursing (DON), and the Administrator revealed that the recommendation was acknowledged but not acted upon. The Consultant Pharmacist expected the facility to implement the monitoring before her next review, but her follow-up was delayed due to a hurricane. The DON admitted awareness of the recommendation but stated it was overlooked despite having sufficient time to address it. The Administrator expressed an expectation for staff to follow pharmacy recommendations when provided.
Failure to Monitor Antipsychotic Medication Side Effects
Penalty
Summary
The facility failed to monitor side effects and behaviors for an antipsychotic medication prescribed to a resident diagnosed with schizophrenia. The resident was admitted with intact cognition and was receiving risperidone, an antipsychotic medication, with dosage adjustments over several months. Despite a pharmacy report suggesting the addition of monitoring instructions for side effects and behaviors, the Medication Administration Records (MAR) from July to November did not include these directions. Interviews with staff revealed that the responsibility for adding monitoring instructions to the MARs was not fulfilled. Nurse #1, who was the resident's full-time nurse, acknowledged the absence of monitoring instructions and admitted it was her oversight. The Consultant Pharmacist had notified the facility of the need for monitoring instructions in August, but due to scheduling disruptions, a follow-up review was delayed. The Director of Nursing was aware of the pharmacist's request but admitted it was overlooked. The Administrator expected staff to address pharmacy recommendations, but this was not done in this case.
Infection Control Deficiencies During Resident Care
Penalty
Summary
The facility failed to implement its infection prevention and control program as evidenced by the actions of two nurse aides during incontinence care for a resident with a stage IV sacral wound. Nurse Aide #1 did not adhere to the facility's hand hygiene policy by failing to sanitize her hands after removing soiled gloves multiple times during the care process. Despite the presence of a hand sanitizer dispenser in the resident's room, the aide neglected to use it, citing nervousness due to being observed. This lapse in hand hygiene occurred after contact with the resident's soiled dressing and before applying lotion to the resident's back. Additionally, Nurse Aide #2 mishandled soiled linen by throwing it on the floor after removing it from the resident's bed, contrary to the facility's policy that requires soiled linen to be placed directly into a designated container. The Unit Manager, who was present during the care, acknowledged witnessing the improper handling of the linen but did not intervene in time to correct the action. Both aides had recently attended a skills fair that included education on infection control, yet these deficiencies were observed during their care of the resident.
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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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