The Oaks-brevard
Inspection history, citations, penalties and survey trends for this long-term care facility in Brevard, North Carolina.
- Location
- 300 Morris Road, Brevard, North Carolina 28712
- CMS Provider Number
- 345462
- Inspections on file
- 19
- Latest survey
- March 5, 2026
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at The Oaks-brevard during CMS and state inspections, most recent first.
Surveyors found that the facility repeatedly failed to obtain and document informed consent before initiating psychotropic medications for several residents with dementia, mood disorders, psychosis, and anxiety. Multiple residents with severe cognitive impairment were receiving antipsychotics, antidepressants, antianxiety agents, and mood stabilizers such as olanzapine, haloperidol, quetiapine, lorazepam, trazodone, duloxetine, venlafaxine, lamotrigine, mirtazapine, and fluoxetine without any record that they or their representatives had been informed of the risks and benefits or had consented. Interviews with the Administrator, DON, ADON, MDS nurse, and SW showed that responsibility for obtaining psychotropic consents was shared between the MDS nurse and SW, but they were not consistently notified of new or changed orders, were unclear that consents were required for all psychotropics (not just antipsychotics), and acknowledged that frequent staff turnover and process gaps led to consents "slipping through the cracks."
A cognitively intact resident with an existing DNR order informed the facility of this status at admission, and both the physician orders and EMR documented the resident as DNR. However, the DNR form was not present in the advance directives notebook at the nurse’s station, one of the two locations designated by the facility for such documentation. Nursing staff reported they rely on either the advance directives notebook or the EMR to determine code status, and the Interim DON and Administrator acknowledged that the notebook and EMR were expected to match, but in this case they did not.
Surveyors found that the facility did not consistently provide required Medicare beneficiary notices when Part A skilled coverage ended for two residents. One resident was discharged home on the last covered day without receiving a Notice of Medicare Non-Coverage (NOMNC), and there was no documentation that the notice had been issued. Another resident received and signed a NOMNC and remained in the facility after skilled coverage ended, but did not receive a Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN). The MDS Coordinator, who is responsible for issuing these notices based on information from therapy and consultation with the provider, reported that the first notice was overlooked while she was on vacation and that she forgot to issue the SNF ABN for the second resident. The Administrator confirmed the expectations for timely issuance of NOMNCs and SNF ABNs and that these expectations were not met in these cases.
Surveyors found that the facility did not request a PASRR Level II evaluation after a resident with a prior Level I status was later diagnosed with major depressive disorder and PTSD and was receiving antidepressant therapy, despite PASRR guidance requiring further screening when new mental illness diagnoses or treatment changes occur. In addition, for another resident with severe cognitive impairment, multiple serious mental illness diagnoses, and a documented PASRR Level II determination specifying specialized services such as psychological testing and psychiatric evaluation, the facility’s comprehensive care plan did not address or incorporate these Level II PASRR recommendations, which staff acknowledged as an oversight.
The facility failed to have a qualified professional directing the activities program, as both the Activity Director and Life Enrichment Specialist lacked formal training and certification. The AD, who transitioned from a nursing assistant role, relied on online resources and previous calendars without formal guidance. The Life Enrichment Specialist also lacked formal training, having only received informal instruction from the AD. The former Administrator was aware of the issue but did not ensure training, while the current Administrator has begun addressing the deficiency.
The facility failed to address and communicate resolutions to concerns raised by residents during Resident Council meetings over 12 months. Meeting minutes lacked documentation of old business, and residents repeatedly voiced issues related to dietary services, staff behavior, and facility maintenance without receiving feedback or resolution. The Activity Director, responsible for recording minutes, admitted to not having formal training, and there was no formal process for documenting or resolving grievances raised during meetings.
The facility failed to provide scheduled group activities during evenings and weekends, leading to resident dissatisfaction and feelings of boredom and loneliness. The Activities Director worked weekdays only, leaving nursing staff to assist with activities during evenings and weekends, but they were unable to provide sufficient support. Residents expressed the importance of having activities to look forward to, and staff confirmed the absence of scheduled activities during these times.
A resident reported her dentures missing shortly after admission, but the facility failed to follow its grievance policy. Despite notifying staff, the resident did not receive follow-up, and the grievance was not logged or resolved within the required timeframe. The Social Worker admitted to forgetting to complete the grievance report, and the Administrator confirmed the grievance process was not followed, resulting in the resident being discharged without her dentures.
The facility did not follow pharmacy recommendations for securing narcotics in the West Hall Medication Storage Room. The narcotic lock box, containing Lorazepam, was found removable from a locked refrigerator. Staff interviews revealed awareness of the issue, which had been identified in a previous pharmacy report, but no resolution had been implemented.
A resident with a history of migraines did not receive her prescribed PRN migraine nasal spray, Stadol, during her stay at the facility due to a failure in the medication reconciliation process. The NP and ADON did not ensure the medication was entered into the MAR, and the double-check system was not effectively implemented. The resident informed staff of her need for the medication, but it was not addressed, and the facility's records lacked a verified discharge summary.
The facility failed to store narcotics in a permanently affixed compartment in a medication room. The narcotic lock box, containing Lorazepam, was found removable inside a locked refrigerator. The ADON believed the medications were secure due to the locked room and refrigerator. The Consultant Pharmacist and DON acknowledged the issue, which had been noted in a previous pharmacy report, but no resolution had been implemented.
A resident reported being held down by staff and denied bathroom access, but the facility failed to follow its abuse policy. The incident was not immediately reported to APS, and the investigation lacked thorough documentation, including interviews with involved parties. The DON delayed responding, and the accused staff were not immediately suspended, resulting in a deficiency in handling the reported abuse.
A facility failed to properly manage a controlled medication, Acetaminophen-Codeine, for a resident who was discharged. An audit revealed 13 tablets were unaccounted for, and the medication card was missing. Interviews with nursing staff showed inconsistencies in handling the narcotic card, and the facility could not provide the controlled substance card count sheet. The DHS suspected the medication card might have been accidentally discarded, and the missing tablets were never recovered.
Failure to Obtain and Document Informed Consent for Psychotropic Medications
Penalty
Summary
The deficiency involves the facility’s failure to obtain and document informed consent for psychotropic medications prior to initiation for multiple residents. For one resident with generalized anxiety disorder and severe cognitive impairment, the record showed an active PRN lorazepam order with no documentation that the responsible party was informed in advance of the risks and benefits or that consent was obtained. Another resident with major depressive disorder, anxiety disorder, borderline personality disorder, hallucinations, and unspecified psychosis, who had intact cognition and no documented behaviors, was receiving risperidone, duloxetine, and lamotrigine without any record that she or her guardian had been informed of the risks and benefits or had consented to these treatments. A third resident with schizophrenia, anxiety disorder, bipolar disorder, and schizoaffective disorder, with moderate cognitive impairment and no behavioral symptoms, was receiving trazodone, venlafaxine, quetiapine, and haloperidol, again with no documentation that the responsible party had been informed in advance or had consented. Another resident with Alzheimer’s disease, major depressive disorder, anxiety disorder, and insomnia, who was severely cognitively impaired and wandering, was receiving mirtazapine, fluoxetine, lamotrigine, and lorazepam on a routine basis. The electronic medical record contained no documentation that the responsible party had been informed in advance of the risks and benefits of these medications or had consented. A resident with dementia, major depressive disorder, and hallucinations was receiving daily olanzapine for hallucinations, with MDS documentation of severe cognitive impairment and daily antipsychotic use, but there was no record that the responsible party had been informed of the risks and benefits or had consented. Another resident with unspecified dementia, generalized anxiety disorder, major depressive disorder, and cognitive communication deficit, who was severely cognitively impaired and receiving antidepressant, antipsychotic, and anticonvulsant medications routinely, was administered olanzapine, lamotrigine, and trazodone without documentation that the representative had been informed in advance of the risks versus benefits or had consented. Interviews with facility staff revealed systemic process issues contributing to the lack of psychotropic consents. The Administrator stated that the Social Worker (SW) and MDS Coordinator were responsible for obtaining psychotropic medication consents but acknowledged that no consent forms could be found for the identified residents and was unsure where the breakdown occurred. The MDS Coordinator and SW both confirmed they shared responsibility for obtaining consents when new psychotropic medications were ordered or existing orders were changed, but reported they were not always informed of new orders or changes, and that providers sometimes added or changed psychiatric medications without notifying them. The Assistant DON/Interim DON and DON stated they believed consents were required for antipsychotics but were not aware of the need for consents for all psychotropic medications, and both cited frequent position changes and acknowledged that obtaining psychotropic consents had “slipped through the cracks.” Psychiatric Nurse Practitioners documented ongoing psychotropic regimens and stability for some residents, including notes that one resident was stable on olanzapine with no indication for gradual dose reduction, and another was stable on olanzapine, lamotrigine, and trazodone with no medication changes needed. However, despite these ongoing psychotropic treatments and routine administration documented on the MARs, the facility’s records lacked corresponding informed consent documentation for each of the psychotropic medications identified in the survey. Staff interviews consistently confirmed the absence of psychotropic consent forms for the affected residents and an inability to explain precisely where in the process the failure to obtain and document consent had occurred.
Failure to Maintain Consistent DNR Documentation in Designated Locations
Penalty
Summary
The deficiency involves the facility’s failure to maintain a resident’s advance directive documentation in both locations designated by facility policy. A cognitively intact resident, admitted with an existing Do Not Resuscitate (DNR) status, reported that he had informed the facility of his DNR upon admission and understood it to mean that staff would not perform CPR if needed. The resident’s physician orders contained an advanced directive order for DNR, and the electronic medical record (EMR) displayed a DNR status in the advance directive banner at the top of the resident’s EMR page. However, when surveyors reviewed the advance directive notebook kept at the nurse’s station, there was no DNR form on file for this resident, despite the EMR and physician orders indicating DNR status. A nurse stated that she would look either in the advance directives notebook or in the EMR to determine a resident’s code status. The Interim DON confirmed she was responsible for ensuring the notebook matched the EMR and for obtaining provider signatures on DNR forms, and acknowledged that the resident’s DNR form was missing from the notebook. The Administrator also stated that code status information in the advance directives binder and EMR should match and that staff were expected to check either source for code status.
Failure to Provide Required Medicare Coverage and Liability Notices
Penalty
Summary
The facility failed to provide required Medicare beneficiary notices related to the end of Medicare Part A skilled coverage for two residents. For one resident, whose Medicare Part A skilled services ended on 10/31/25 and who discharged home the same day, review of the medical record and the facility’s Beneficiary Notice worksheet showed no evidence that a Notice of Medicare Non-Coverage (NOMNC) was reviewed with or provided to the resident or the responsible party. The MDS Coordinator, who is responsible for issuing NOMNCs and SNF ABNs, stated that therapy staff notify her when skilled coverage is scheduled to end and she then consults with the provider to determine if any additional skilled needs exist before issuing the appropriate notice. She reported that when this resident discharged home, the social worker and financial counselor were covering her duties while she was on vacation and the NOMNC issuance was overlooked. The Administrator confirmed that the MDS Coordinator is expected to issue a NOMNC at least two days before skilled services end and that there was no documentation that this occurred for this resident. For another resident, a NOMNC was discussed with and signed by the resident, indicating that Medicare Part A coverage for skilled services would end on 11/15/25, and the resident remained in the facility after skilled coverage ended. However, review of the medical record revealed no evidence that a Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN) was reviewed with or provided to this resident. The MDS Coordinator again stated she is responsible for issuing both NOMNCs and SNF ABNs and explained her usual process of being informed by therapy when skilled coverage is ending and then determining if any other skilled needs exist before issuing the applicable notices. She acknowledged that she simply forgot to provide a SNF ABN to this resident when the NOMNC was issued. The Administrator stated that the MDS Coordinator is responsible for issuing a SNF ABN when a resident remains in the facility and/or appeals the NOMNC and that he would have expected this resident to receive a SNF ABN when Medicare Part A skilled services ended.
Failure to Request PASRR Level II Evaluation and Integrate Level II Recommendations Into Care Planning
Penalty
Summary
The facility failed to comply with PASRR requirements for residents with serious mental illness. For one resident with an existing Level I PASRR determination, subsequent psychiatric progress notes documented new diagnoses of chronic, stable major depressive disorder and PTSD, along with treatment with sertraline and ongoing monitoring. The resident’s MDS assessments reflected active diagnoses of anxiety disorder, depression, and PTSD, as well as use of antianxiety and antidepressant medications and moderate cognitive impairment. Despite the PASRR Determination Notification specifying that no further screening was required unless a significant change occurred suggesting a mental illness diagnosis or change in treatment needs, the facility did not submit a request for a Level II PASRR evaluation after these new mental illness diagnoses were identified. The social worker, who was responsible for submitting Level II requests, stated she was not always notified of new mental illness diagnoses and acknowledged that no Level II request was submitted for this resident following the new diagnoses. For another resident with a documented Level II PASRR determination, the facility failed to incorporate the PASRR recommendations into the resident’s care plan. This resident had cumulative diagnoses including major depressive disorder, anxiety disorder, borderline personality disorder, hallucinations, and unspecified psychosis, with MDS findings of severe cognitive impairment, delusions, and frequent behavioral symptoms. A Level II PASRR Determination Notification indicated that nursing placement was appropriate and specified specialized services of psychological testing and psychiatric evaluation. However, review of the comprehensive care plan showed no care plan addressing the Level II PASRR specialized services determination. The MDS Coordinator, who was responsible for developing care plans, confirmed the resident had a Level II PASRR and that a care plan should have been developed, but it was not, which was described as an oversight.
Lack of Qualified Activities Program Leadership
Penalty
Summary
The facility failed to ensure that the activities program was directed by a qualified professional, as neither the Activity Director (AD) nor the Life Enrichment Specialist had received formal activities training or certification. The AD, who had previously worked as a nursing assistant and then as a Life Enrichment Specialist, assumed the AD position in December 2023 without any formal training or certification. She relied on online resources and previous activity calendars to guide her work but expressed a desire for formal training to improve the activities program for residents. Similarly, the Life Enrichment Specialist, who also transitioned from a nursing assistant role, had only received informal training from the AD and had not completed any state training courses or obtained certification. Interviews with the former and current Administrators revealed a lack of oversight and follow-through regarding the training and certification of the AD and Life Enrichment Specialist. The former Administrator acknowledged awareness of the lack of formal training and certification but could not recall why it was not pursued. The current Administrator, who began employment in October 2024, was recently made aware of the issue and had initiated discussions with the regional office to arrange formal training and certification for both staff members. The deficiency had the potential to affect all residents at the facility, as the activities program was not being directed by qualified professionals.
Failure to Address Resident Council Concerns
Penalty
Summary
The facility failed to effectively address and communicate resolutions to concerns raised by residents during Resident Council meetings over a period of 12 out of 14 months. The Resident Council meeting minutes consistently lacked documentation of old business, and there was no indication that previous concerns were read, approved, revised, or resolved. Residents repeatedly voiced issues related to dietary services, staff behavior, and facility maintenance, yet there was no evidence of follow-up or resolution communicated back to the residents. Interviews with residents revealed a shared sentiment that their concerns were not being adequately addressed by the facility staff. Residents expressed frustration over the lack of feedback and resolution to their issues, with some concerns persisting over several months. The Resident Council President acknowledged that while some issues might take time to resolve, the residents would appreciate communication regarding the efforts being made to address their concerns. The Activity Director, responsible for recording the minutes of the Resident Council meetings, admitted to not having received formal training on how to document or address the concerns raised during these meetings. The Director of Nursing and the Social Worker also confirmed that there was no formal process in place for documenting or resolving grievances raised during Resident Council meetings. The previous Administrator did not ensure that the concerns were documented or resolved, leading to a lack of accountability and communication with the residents.
Lack of Evening and Weekend Activities
Penalty
Summary
The facility failed to provide scheduled group activities during evenings and weekends, which was important to the residents. The December 2024 activity calendar showed that activities were only scheduled on weekdays, with no evening or weekend activities except for a church service every other Sunday. The Activities Director, who worked Monday through Friday, was responsible for all activities and relied on nursing staff to assist residents during evenings and weekends. However, the nursing staff was not able to provide sufficient support for activities during these times. Residents expressed dissatisfaction with the lack of scheduled activities during evenings and weekends, leading to feelings of boredom, loneliness, and depression. Resident #4, #44, #51, and #56, all cognitively intact, reported during a resident council meeting that they had no scheduled activities during these times, except for the occasional church service. They emphasized the importance of having activities to look forward to and the negative impact of their absence on their mental well-being. Interviews with facility staff, including a nurse and a nursing assistant, confirmed the absence of scheduled group activities during evenings and weekends. They noted that residents were left to find their own activities, such as watching television or doing puzzles, due to insufficient staffing to assist with activities. The Administrator acknowledged the issue and mentioned the facility's ongoing efforts to hire an activity assistant for evenings and weekends, as well as potential schedule adjustments for the Activities Director.
Failure to Implement Grievance Policy for Missing Dentures
Penalty
Summary
The facility failed to implement its grievance policies and procedures when a resident reported her dentures missing. The resident, who was cognitively intact and admitted for aftercare following joint replacement surgery, informed staff that her dentures had been missing since the day after her admission. Despite notifying multiple staff members, the resident did not receive follow-up regarding the resolution of her grievance. The facility's grievance policy requires grievances to be resolved within three business days, but there was no record of a grievance being filed or resolved within this timeframe. The Social Worker (SW) acknowledged awareness of the missing dentures and stated that the facility investigated missing items. However, the SW admitted to forgetting to complete the grievance report until it was requested. The Director of Nursing (DON) and Activities Director (AD) searched for the dentures, including checking the trash and dumpster, but were unable to locate them. The SW stated that the facility was not liable to replace the dentures as they could not verify how they were lost, and there was no documentation of follow-up with the resident regarding the grievance. The Administrator confirmed awareness of the missing dentures and stated that a grievance report should have been started immediately. However, the grievance was not logged, and the Administrator had not reviewed or signed the grievance report. The Administrator and SW both indicated that the grievance process was not followed as per the facility's policy, resulting in the resident being discharged without her dentures and without a resolution to her grievance.
Failure to Securely Affix Narcotic Lock Box in Medication Storage Room
Penalty
Summary
The facility failed to adhere to pharmacy recommendations for the secure storage of narcotics in one of the medication rooms reviewed. During an observation of the West Hall Medication Storage Room, it was found that the narcotic lock box, which contained four unopened vials of Lorazepam, was inside a locked refrigerator but was not permanently affixed, making it removable. This issue was previously identified in the Consultant Pharmacy report dated November 26, 2024, which noted that controls in the refrigerator were under double lock and key but were in the process of being secured in a non-removable lock box. Interviews with facility staff, including the Assistant Director of Nursing (ADON), the Consultant Pharmacist, the Director of Nursing (DON), and the Administrator, revealed awareness of the issue. The ADON believed the medications were appropriately secured due to the locked room and refrigerator. The Consultant Pharmacist confirmed the need for the narcotic box to be permanently affixed, as noted in the November report. The DON acknowledged the issue had persisted since her hiring in April 2021, and the Administrator admitted ongoing discussions about securing the narcotic box without reaching a resolution.
Failure to Administer PRN Migraine Medication
Penalty
Summary
The facility failed to prevent a significant medication error involving a resident who was admitted with a discharge order for a PRN migraine nasal spray, Stadol, which was not entered into the facility's medication administration record (MAR). The resident, who was cognitively intact and had a history of migraines, did not receive the prescribed medication during her stay at the facility. Despite informing multiple nursing staff and discussing the issue with the doctor, the resident's need for the migraine medication was not addressed. The Nurse Practitioner (NP) and Assistant Director of Nursing (ADON) were involved in the medication reconciliation process but failed to ensure the Stadol order was entered into the system. The NP recalled that the ADON had contacted her for medication reconciliation, and she had not ordered any medications to be stopped. However, the ADON admitted to having trouble entering the order into the computer system and forgot to return to it, likely due to interruptions. The double-check system, which involves another nurse verifying the entered medications, was not effectively implemented, as the ADON was unsure who had performed the second check. The facility's Consulting Pharmacist and Medical Director confirmed that the medication reconciliation process was not completed correctly, as there was no verified discharge summary in the resident's electronic medical record. The Medical Director, who was unaware of the omission, noted that the Stadol order was not continued as intended. The Director of Nursing (DON) and the facility Administrator were also unaware of the missing medication order and the lack of a verified discharge summary in the resident's record.
Narcotic Storage Deficiency in Medication Room
Penalty
Summary
The facility failed to store narcotics in a locked, permanently affixed compartment in one of the medication rooms reviewed. During an observation of the West Hall Medication Storage Room, it was found that the narcotic lock box was inside a locked refrigerator but was not permanently affixed, making it removable. This lock box contained four unopened vials of Lorazepam, a Schedule IV antianxiety medication. The Assistant Director of Nursing (ADON) believed that the medications were appropriately secured since both the medication storage room and the refrigerator were locked. The Consultant Pharmacist confirmed that the narcotic box should be permanently affixed to the refrigerator and noted that this issue had been identified in the November 2024 pharmacy report. The Director of Nursing (DON) acknowledged that the narcotic box had not been permanently affixed since her hiring in April 2021 and was aware of the requirement for it to be secured. The Administrator also acknowledged awareness of the issue and mentioned ongoing discussions about how to affix the narcotic box, but no resolution had been reached.
Failure to Implement Abuse Policy and Conduct Thorough Investigation
Penalty
Summary
The facility failed to implement its abuse policy and procedure in the case of a resident who reported being held down by staff and denied access to the bathroom. The facility's policies required immediate reporting of any allegations of abuse to the administrator and notification of Adult Protective Services (APS), neither of which occurred in this instance. The initial allegation report was marked as an abuse investigation, but APS was not notified, and the investigation lacked thorough documentation, including interviews and statements from involved parties. The resident, who was hard of hearing, reported that three staff members held his arms down and yelled at him not to ring the call light. Despite the report, there was no interview or statement from the resident included in the investigation, nor were there statements from the accused staff members or other relevant personnel. The Director of Nursing (DON) was informed of the incident but did not immediately respond, as the situation was deemed non-urgent. The DON later interviewed the resident, but the description of events changed, and the accused staff members were not immediately suspended. Interviews with staff revealed inconsistencies in the handling of the incident. The Activity Director (AD) and a nursing assistant reported the incident to the DON, but neither was interviewed or asked to provide a written statement. The DON and the former administrator conducted interviews with the accused staff, leading to suspensions, but the investigation was not completed promptly, and APS was not notified. The facility's failure to follow its abuse policy and conduct a timely and thorough investigation resulted in a deficiency in handling the reported abuse incident.
Controlled Medication Mismanagement
Penalty
Summary
The facility failed to maintain effective systems for the identification, storage, and return of a controlled medication, specifically Acetaminophen-Codeine, for a resident who was discharged. The resident had an order for this opioid medication to be administered as needed for severe pain. Upon discharge, the facility did not ensure the remaining medication was properly accounted for and returned to the pharmacy. An audit conducted by the Assistant Director of Health Services (ADHS) revealed that 13 tablets of the medication were unaccounted for, and the medication card was missing. Interviews with nursing staff who worked on the relevant medication cart indicated a lack of clarity and consistency in handling the narcotic card. Some nurses recalled seeing the card, while others did not, and there was no specific recollection of dates or times. The facility was unable to provide the controlled substance card count sheet for the period in question, further complicating the situation. The responsible party for the resident confirmed that the medication was not sent home with the resident, and a prescription was provided upon discharge. The Director of Health Services (DHS) and the ADHS conducted a thorough investigation, including interviews and a review of the medication carts. The DHS suspected that the medication card might have been accidentally discarded during the collection of discontinued medications. Despite efforts to locate the missing tablets, they were never recovered. The facility acknowledged the deficiency and recognized the need for a revised medication handling process to prevent future occurrences.
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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