Trinity Elms
Inspection history, citations, penalties and survey trends for this long-term care facility in Clemmons, North Carolina.
- Location
- 7449 Fair Oaks Drive, Clemmons, North Carolina 27012
- CMS Provider Number
- 345565
- Inspections on file
- 20
- Latest survey
- March 19, 2026
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Trinity Elms during CMS and state inspections, most recent first.
Multiple MDS assessments were inaccurately coded when one resident admitted with pneumonia and meningitis, who had documented IV access, midline catheter use, and IV ceftriaxone therapy, was not coded for IV access or IV antibiotics on the MDS. Another resident with Type 2 DM receiving subcutaneous Tirzepatide was incorrectly coded as having received an insulin injection after the MDS nurse mistakenly assumed Tirzepatide was insulin, despite no insulin being documented on the MAR. A third resident with anxiety disorder had multiple documented behaviors such as yelling, hitting, aggression, agitation, exit seeking, and refusing care during the MDS look-back period, but was coded as having no behaviors because the social work staff relied only on direct observation and did not review the electronic medical record for documented behaviors.
A resident with chronic pain, mild dementia, severe neurocognitive disorder, debility, and impaired mobility was admitted with documented high fall risk and physician orders for PRN acetaminophen ER and a daily lidocaine patch for pain. Within 48 hours, the MDS nurse completed a baseline care plan that addressed transfer status, therapy, and dietary needs but omitted goals and interventions for pain management and did not include fall prevention measures, despite the fall risk evaluation indicating that prevention protocols should be initiated and documented. The resident’s representative reported ongoing pain and perceived high fall risk and wanted staff to be aware of these needs, while the DON and Administrator later acknowledged that the baseline care plan should have contained this essential information.
A resident with documented episodes of grabbing, hitting, physical aggression, agitation, anxiousness, and exit-seeking did not have communication or behavior needs addressed in the comprehensive care plan. Although the admission MDS showed adequate hearing with hearing aids and no behaviors at that time, the CAA identified communication as a triggered area to be care planned. The Social Work Assistant completed the CAA based only on the resident’s behavior during the assessment, did not review the EMR behavior monitoring reports, and was unaware of the need to do so. As a result, no communication or behavior interventions were added to the care plan, a lapse later acknowledged by both the Social Work Assistant and the DON.
A resident with dementia, failure to thrive, a fall history, and HTN was found on the floor by an RN, who assessed for pain and injury but did not notify the NP, responsible party, DON, or Medical Director of the fall and entered the event in the EMR as an injury rather than a fall. Two days later, the resident reported new right knee pain and swelling; the NP and family were informed only of the pain, not the prior fall, and an x-ray was ordered. Over the following days, the resident continued to report pain, received multiple analgesics, and underwent imaging, culminating in a CT that showed multiple right hip and pelvic fractures. The NP, Medical Director, and resident representative all reported they were not made aware of the fall until after the CT results and subsequent internal review, and hospital records later documented admission for a displaced right acetabular fracture and severe pain with functional decline after a fall at the facility.
A resident with dementia, gait abnormalities, and a history of falls was found on the floor in front of a wheelchair and assessed by an RN, who documented no pain or injury and returned the resident to a wheelchair. The RN entered the event in the EMR as an injury rather than a fall, did not complete required fall risk and post‑fall evaluations, and did not report the fall in shift report, so management and the primary provider were not promptly notified and automated fall protocols were not triggered. Over subsequent days, the resident repeatedly complained of right leg pain with documented pain scores and received PRN analgesics while outside imaging orders were delayed and not clearly communicated to the NP. When the NP later assessed the resident for persistent discomfort and limited ROM, a hip/pelvis x‑ray and then a CT scan were ordered, ultimately revealing multiple right hip and pelvic fractures. Interviews and record review showed that the fall was not disclosed to the NP or family until after the CT results and internal investigation, demonstrating a breakdown in communication, documentation, and interdisciplinary coordination around the resident’s fall and subsequent pain complaints.
A medication aide mistakenly administered a set of medications intended for another resident to a resident with severe cognitive impairment after misidentifying her during a medication pass. The error involved multiple medications, including antihypertensives and psychotropics, and was discovered after the aide realized the mistake and reported it. The resident was monitored and found to be stable, with no acute distress or adverse reactions noted.
The facility failed to submit accurate PBJ data to CMS, missing RN hours and 24-hour licensed nursing coverage for several days in a quarter. Despite having the required staffing, errors in reporting led to the deficiency, which was later corrected.
A facility failed to maintain consistent advance directive information for a resident, resulting in a discrepancy between the EMR and paper medical record. The resident's EMR indicated a full code status, while the paper record showed a signed DNR form. Staff interviews confirmed the inconsistency, with the DON and Administrator expecting records to match.
The facility failed to post required cautionary and safety signage for three residents receiving oxygen therapy. Despite physician orders for continuous oxygen administration, observations revealed that these residents were receiving oxygen without any signage indicating its use. Interviews with the DON and Administrator confirmed that signage was expected but not implemented.
A resident, not approved to self-administer medications, was found with medications left unsecured on their overbed table. The nurse mistakenly believed the resident could self-administer, leading to a breach in medication storage protocols. The DON confirmed this was against facility policy.
A nonverbal resident with diabetes in an LTC facility developed skin wounds during a shower, which were not promptly reported to the medical provider. The resident's condition worsened overnight, leading to a diagnosis of deep partial thickness burns. The delay in notification increased the risk of infection, especially given the resident's diabetes.
A resident with severe cognitive impairment was left unattended in a shower by a nurse aide, resulting in deep partial thickness burns to her thighs and mons pubis. The resident, who required total assistance for care, was found with peeling skin after being left with running water. The incident highlighted a lack of supervision and failure to follow proper procedures, leading to the resident's hospitalization and treatment.
Inaccurate MDS Coding for IV Therapy, Insulin Use, and Behaviors
Penalty
Summary
The deficiency involves inaccurate coding of Minimum Data Set (MDS) assessments for multiple residents, resulting in failure to capture IV therapy, IV antibiotic use, insulin use, and behavioral symptoms. One resident was admitted with pneumonia and meningitis requiring IV access and IV antibiotic medications. Documentation showed the resident arrived with IV access in the right antecubital fossa, had physician orders for IV ceftriaxone every 12 hours, and received IV antibiotics and saline flushes over several days, with notes indicating use of a midline catheter. However, the discharge return not anticipated MDS assessment did not indicate the presence of a midline IV access or that IV antibiotics were received upon admission, during the stay, or at discharge. The MDS Nurse later acknowledged that IV access and IV antibiotic use were not marked and that this was an error. Another resident with Type 2 diabetes mellitus with hyperglycemia had a physician order for Tirzepatide to be administered subcutaneously once weekly, and the Medication Administration Record confirmed that this medication was given as ordered. There was no indication on the MAR that the resident received any insulin injections. Despite this, the admission MDS assessment coded that the resident had received one insulin injection. The MDS Nurse who completed the assessment stated she coded one insulin injection because she believed Tirzepatide was considered insulin and later realized this was incorrect, confirming that the MDS had been inaccurately coded. A third resident admitted with an anxiety disorder exhibited multiple documented behaviors during the MDS assessment look-back period, including grabbing others, hitting, physical aggression, agitation, anxiousness, exit seeking, yelling, throwing medication, refusing care, restlessness, and wandering. These behaviors were recorded on behavior monitoring reports and in progress notes by nursing staff and the Administrator. Despite this documentation, the admission MDS with an Assessment Reference Date within this period coded the resident as having no behaviors, although it did indicate severe cognitive impairment and receipt of antianxiety medication. The Social Work Assistant responsible for coding behaviors on the MDS stated she did not observe these behaviors during the assessment period, was not aware she needed to review the electronic medical record for documented behaviors, and was unaware that such behaviors had been documented, leading to the omission of behaviors on the MDS.
Failure to Include Fall Risk and Pain Management in Baseline Care Plan
Penalty
Summary
The facility failed to develop a baseline care plan that addressed a newly admitted resident’s immediate needs related to fall prevention and pain management. Record review showed the resident had diagnoses of chronic neck pain, chronic pain syndrome, mild dementia, severe major neurocognitive disorder, debility, and impaired mobility. Hospital documentation indicated a recent cognitive and functional decline, increased confusion, difficulty ambulating with a walker, generalized weakness, and reduced mobility. On admission, the facility’s fall risk evaluation identified the resident as being at high risk for potential falls, with instructions that fall prevention protocols should be initiated immediately and documented on the care plan. Physician orders at admission included PRN acetaminophen extended release for pain and a daily lidocaine 4% patch for lower back pain. Despite this information, the baseline care plan completed within 48 hours of admission did not include goals or interventions for the resident’s chronic pain syndrome and did not address the resident’s immediate needs related to fall risk prevention. The MDS nurse who completed the baseline care plan stated it included transfer status, therapy, and dietary information and believed it met minimum requirements for basic safety. The resident’s representative reported that the resident had a history of chronic pain requiring medication for comfort, that his pain continued after admission, and that she believed he was at high risk for falls due to his physical and mental condition, and wanted staff to be aware of these issues. The DON and Administrator both stated that a baseline care plan should include the minimum healthcare information necessary to meet a resident’s needs, and the DON acknowledged that the resident’s high fall risk and pain should have been included, but they were not.
Failure to Develop Communication and Behavior Care Plans for a Resident
Penalty
Summary
The deficiency involves the facility’s failure to develop a comprehensive care plan addressing communication and behavioral needs for one resident. The resident was admitted on a specified date, and behavior monitoring and intervention reports documented multiple episodes of problematic behaviors, including grabbing others, hitting others, physical aggression toward others, agitation, anxiousness, and exit-seeking on consecutive days. The admission MDS assessment indicated the resident had adequate hearing with hearing aids, was usually understood and usually understood others, and showed no behaviors at that time. The Care Area Assessment (CAA) summary, completed shortly after admission by the previous Social Work Assistant, showed that communication was a triggered care area and stated that communication would be addressed in the care plan. Despite these findings, review of the resident’s care plan, dated shortly after admission with a later revision date, revealed no care plan or interventions in the areas of communication or behaviors. In a telephone interview, the previous Social Work Assistant confirmed she completed the communication CAA summary and acknowledged the resident should have had a communication care plan, but she did not know why one had not been developed. She stated she based her CAA answers solely on the resident’s behavior during the assessment, when no behaviors were observed, and she did not review the electronic medical record’s behavioral monitoring and intervention report because she did not know she needed to do so. The DON also stated that the resident should have had communication and behavior care plans and was unsure why they had not been completed.
Failure to Notify Provider and Representative of Resident Fall and Subsequent Pain
Penalty
Summary
The deficiency involves the facility’s failure to immediately notify the nurse practitioner (NP) and the resident representative of a resident’s fall and to clearly communicate the occurrence of that fall when later reporting new pain symptoms. The resident, who had non-Alzheimer’s dementia, adult failure to thrive, a history of falling, and hypertension, was found on the floor in front of her wheelchair on 1/28/26. Nurse #7, who had just started her shift, assessed the resident for pain and injury, checked range of motion, and documented that the resident denied pain and had no apparent injury. Nurse #7 did not notify the provider, the family, or the DON of the fall on that date and believed the fall was witnessed by the Scheduler. The DON later stated that the incident was entered in the electronic medical record as an “injury” rather than a “fall,” which prevented the system from triggering the facility’s fall risk and post-fall evaluations. On 1/30/26, the resident began complaining of right knee pain, rated 4/10, and was given acetaminophen. A health status note by Nurse #11 documented that the NP was notified of the resident’s knee pain and slight swelling, and an x-ray was ordered. The resident’s family, who visited that day, was also notified of the complaint of right knee pain, but neither the NP nor the family was informed that the resident had been found on the floor two days earlier. The NP later confirmed she was never officially notified of the 1/28/26 fall and ordered the x-ray based solely on the reported pain. The NP stated she typically would be called when a resident fell and that she did not learn of the fall until 2/11/26, after CT results were available and the facility began an internal investigation. In the days following the onset of pain, the resident continued to report pain of varying intensity, including right lower extremity thigh/knee pain, and received acetaminophen, tramadol, and hydrocodone-acetaminophen. An x-ray could not be completed on one date due to snow, and the family initially requested waiting to send the resident out, later agreeing to further evaluation when the pain migrated to the hip. An x-ray of the knee was eventually done and was reported as fine, with a recommendation for CT if pain persisted. A CT scan performed on 2/9/26 revealed multiple serious fractures of the right hip and pelvis and flattening of the superior lateral right femoral head. The resident representative stated she was not notified of the 1/28/26 fall and only became aware of it in February when discussing CT results with the NP. The Medical Director also reported not being informed of the fall until 2/11/26, learning of it through record review. Hospital records documented that the resident was admitted with a displaced transverse-posterior fracture of the right acetabulum and severe pain with functional decline after experiencing a fall at the nursing facility.
Failure to Document and Communicate Fall Led to Delayed Identification of Fractures and Ongoing Pain
Penalty
Summary
The deficiency involves the facility’s failure to implement effective systems for communication, collaboration, assessment, and documentation following a resident fall, resulting in delayed recognition and response to injury and ongoing pain. Resident #33, who had hypertension, non‑Alzheimer’s dementia, adult failure to thrive, generalized muscle weakness, gait and mobility abnormalities, a history of falls, and used a wheelchair, was care planned as being at moderate risk for falls with interventions such as a wing‑tip mattress and prompt response to assistance needs. On the afternoon of 1/28/26, the Scheduler observed the resident already on the floor, sitting on her buttocks in front of her wheelchair, and summoned a nurse and a medication aide. Nurse #7 assessed the resident, checked range of motion, obtained vital signs, and asked about pain; the resident denied pain, and no apparent injury was noted. The resident was assisted back into her wheelchair and taken to the nurse’s station for brief observation before returning to routine activities. Despite this event, Nurse #7 did not document the occurrence as a fall in the electronic medical record, instead entering it as an “injury” incident type, which did not trigger the facility’s fall‑related User‑Defined Assessments (Fall Risk and Post Fall Evaluations). There was no contemporaneous Post Fall Evaluation or Fall Risk Evaluation completed for the 1/28/26 event, and the fall was not included in the shift report. As a result, management, the primary provider, and the resident’s representative were not promptly informed of the fall. The DON later confirmed that the misclassification of the event in the EMR prevented automatic initiation of the fall assessments and associated management investigation. The NP stated she was never officially notified of the 1/28/26 fall at the time it occurred and that she typically expected a call from the facility when a resident fell. Following the 1/28/26 incident, the resident began complaining of right knee pain on 1/30/26, with documented pain scores and administration of acetaminophen and later tramadol and hydrocodone‑acetaminophen. Nursing staff notified the NP of knee pain and slight swelling, and a right knee x‑ray was ordered on 1/30/26; due to weather and scheduling issues with the outside imaging company, this x‑ray was delayed, and the NP was not made aware of the delay until a later facility visit. The 1/30/26 knee x‑ray, when eventually completed, showed no acute fracture. On 2/4/26, during an on‑site visit, the NP observed the resident to be uncomfortable, irritable, frequently repositioning, and apparently not bearing weight on the right side, with complaints of pain and limited ROM of the right leg; staff at that time reported “no known injury.” Based on this assessment, the NP ordered a right hip/pelvis x‑ray, which showed arthritic changes and osteopenia but recommended CT if clinical suspicion for fracture persisted. A CT scan performed on 2/9/26 revealed multiple serious fractures of the right hip and pelvis. Throughout this period, the resident had repeated documented pain scores, and the NP and Medical Director both reported that they and the family only became aware of the 1/28/26 fall after the CT results and subsequent internal investigation, underscoring that the initial fall event and subsequent pain complaints were not effectively communicated or linked by staff to a potential injury from the fall. A late entry Post Fall Note was created by the ADON on 2/12/26, backdated to 1/28/26, describing the resident on the floor in front of her wheelchair, the assessment with no apparent injury, and the use of the PAINAD scale, but this documentation occurred only after the CT scan identified fractures and after the facility began investigating the cause of the injuries. Interviews with the DON, Unit Manager, NP, Medical Director, and other staff confirmed that the fall was initially treated as a non‑injurious event, that required fall assessments and notifications were not completed at the time, and that there were gaps in communication about both the fall and the delays in obtaining imaging. The surveyors concluded that the facility failed to implement effective systems to ensure timely communication and collaboration regarding the resident’s care, including accurate classification and documentation of the fall, prompt notification of the provider and resident representative, and timely follow‑up on persistent pain and imaging orders. Hospital records later documented that the resident was admitted after a fall at the nursing facility with a serious right hip socket fracture and severe pain and difficulty moving. The Medical Director’s first post‑fall visit with the resident occurred on 2/11/26, well after the 1/28/26 fall, and she reported that at that time the resident did not appear to be in pain but was agitated. The NP stated that had she known about the fall when it occurred, she might have ordered different or more extensive imaging earlier and would have considered sending the resident to the emergency department if injury was suspected. The deficiency centers on the facility’s failure to recognize, document, and communicate the 1/28/26 fall as such, failure to complete required fall‑related assessments, and failure to effectively coordinate provider notification and diagnostic follow‑up in the context of the resident’s ongoing pain and functional changes. Overall, the events show that the resident’s fall was not properly reported or documented in real time, the EMR entry did not trigger the facility’s fall management protocols, and key clinical staff and the resident’s representative were not promptly informed of the fall. Subsequent pain complaints, behavioral changes, and functional limitations were managed without clear linkage to a known fall event, and imaging orders were delayed or not effectively followed up, contributing to a prolonged period before the resident’s fractures were identified. These actions and inactions, as documented by staff interviews, record reviews, and practitioner statements, constitute the basis of the cited deficiency for failure to provide treatment and care in accordance with orders, resident preferences, and goals through effective communication and collaboration.
Medication Error Due to Resident Misidentification
Penalty
Summary
A medication error occurred when a medication aide administered a set of medications intended for one resident to another resident with severe cognitive impairment. The aide had previously given the correct morning medications to the resident, but later, due to changes in the resident's appearance and a case of mistaken identity, she addressed the resident by another's name and administered the wrong medications. The aide realized the error about an hour later and reported it to the nurse on duty. The resident who received the incorrect medications had a complex medical history, including hypertensive heart disease with heart failure, atrial fibrillation, and dementia with behaviors. The medications erroneously administered included multiple antihypertensives, an antipsychotic, an antidepressant, an antibiotic, and other medications not prescribed for her. At the time of the error, the resident was alert, at her baseline, and did not exhibit any acute distress or adverse reactions, though her blood pressure was monitored and found to be slightly low but stable. The incident was confirmed through interviews with the medication aide, the nurse, the nurse practitioner, and the medical director, as well as a review of the resident's medical records, EMS, and hospital documentation. The facility's DON stated that staff are expected to follow the six rights of medication administration, which were not adhered to in this case, resulting in the administration of another resident's medications to the wrong individual.
Inaccurate PBJ Reporting of RN Hours and Nursing Coverage
Penalty
Summary
The facility failed to submit accurate payroll data on the Payroll Based Journal (PBJ) report to the Centers for Medicare and Medicaid Services (CMS) regarding Registered Nurse (RN) hours and licensed nursing coverage for 24 hours per day. This issue was identified for one of the three quarters reviewed, specifically Quarter 4 of 2024. The PBJ report indicated that there were no RN hours recorded for several days in September 2024, and the facility also failed to have licensed nursing coverage for 24 hours per day on multiple days during the same month. Upon review of the Posted Daily Nursing Staffing Forms, Daily Staffing Sheet, and nursing staff time detail reports, it was found that there were indeed RN hours and 24-hour licensed nursing coverage for the days in question. An interview with the Human Resources Payroll Manager revealed that the PBJ data file submitted for September 2024 was initially rejected due to errors, which were later corrected and resubmitted successfully. The Administrator confirmed that the facility had the required RN hours and licensed nursing staff, attributing the issue to a reporting error.
Inconsistent Advance Directive Information for Resident
Penalty
Summary
The facility failed to maintain consistent and accurate advance directive information for a resident, leading to a discrepancy between the electronic medical record (EMR) and the paper medical record. The resident, who was moderately cognitively impaired, had a physician's order in the EMR indicating a full code status dated 12/12/24, while the paper medical record at the nurse's station contained a signed Do Not Resuscitate (DNR) form dated 12/16/24. This inconsistency was identified during staff interviews and record reviews. Nurse #1 confirmed the discrepancy and stated that in an emergency, she would first check the paper medical record. If there was a discrepancy, she would consult with the Director of Nursing (DON). The DON and the Administrator both expressed that their expectation was for the EMR and paper medical records to match. However, the inconsistency remained, indicating a failure in the facility's process to ensure that critical information regarding the resident's code status was accurately reflected across all records.
Failure to Post Oxygen Safety Signage
Penalty
Summary
The facility failed to post cautionary and safety signage outside the rooms of three residents who were receiving oxygen therapy. Resident #57, admitted with pneumonia due to hemophilus influenzae, had a physician's order for continuous oxygen administration via nasal cannula at 1 Liter/minute. Observations on two separate occasions revealed that Resident #57 was receiving oxygen without any cautionary signage posted at the entrance to her room. Similarly, Resident #69, admitted with acute respiratory failure with hypoxia, had orders for oxygen titration up to 2 Liters/minute. Observations showed that Resident #69 was receiving oxygen at varying levels without the required safety signage outside his room. Resident #48, who was admitted with pneumonia, chronic respiratory failure with hypoxia, and chronic obstructive pulmonary disease, also had a physician's order for continuous oxygen at 2 Liters/minute. Observations confirmed that Resident #48 was receiving oxygen without any safety signage posted at the entrance to her room. Interviews with the Director of Nursing and the Administrator revealed that it was their expectation that the required oxygen signage be posted for residents receiving oxygen, indicating a lapse in adherence to safety protocols.
Failure to Secure Medications for Resident
Penalty
Summary
The facility failed to secure medications for a resident who was not approved to self-administer medications. Resident #77, who was admitted with diagnoses including cerebral infarction, hypertension, and anxiety, was assessed on 9/13/24 and found to require assistance with oral medications. Despite this assessment, medications were observed on the resident's overbed table during a survey on 1/13/25. The resident confirmed that it was common practice for the nurse to leave medications on the table for later consumption. Nurse #1, who left the medications on the table, mistakenly believed that the resident was approved to self-administer. The medications included Gabapentin, Labetalol, Clopidogrel, Zetia, Lasix, Isosorbide, Cozaar, a multivitamin, and Zoloft. The Director of Nursing confirmed that the medications should not have been left at the bedside, indicating a lapse in following the facility's medication storage protocols.
Failure to Notify Medical Provider of Resident's Condition Change
Penalty
Summary
The facility staff failed to notify the medical provider of a change in condition for a nonverbal resident with diabetes when new skin wounds were observed. The resident, who was severely cognitively impaired and nonverbal, was found to have skin tears on both thighs during a scheduled shower. The nurse on duty assessed the resident and noted redness and skin peeling on the thighs and mons pubis. Despite the visible injuries, the nurse did not notify the medical provider due to time constraints and instead passed the information to the oncoming nurse. The subsequent nurse also failed to notify the medical provider, assuming the previous nurse had done so. The resident's condition worsened overnight, with increased redness and irritation observed by the morning shift nurse. It was only after the wound nurse's assessment that the Assistant Director of Nursing was notified, who then contacted the medical provider. The resident was sent to the emergency department and diagnosed with deep partial thickness burns. Interviews with the medical director and dermatologist confirmed that the facility should have contacted the medical provider immediately upon noticing the change in the resident's condition. The dermatologist's assessment indicated that the injuries were consistent with thermal burns, possibly from hot water or a hot washcloth. The delay in notifying the medical provider increased the risk of infection, especially given the resident's diabetes and the severity of the burns.
Resident Left Unattended in Shower Results in Burns
Penalty
Summary
The facility staff failed to adequately supervise a severely cognitively impaired and nonverbal resident during a shower, leading to significant injuries. On the specified date, a nurse aide left the resident unattended and naked on a shower bed with the water running. Upon returning, the aide found the resident with a pool of water over her thighs and genital area, and the top layer of her skin was peeling off. The resident was subsequently diagnosed with deep partial thickness burns to her thighs and mons pubis, requiring hospitalization and treatment. The resident involved had a complex medical history, including lumbar degenerative disc disease, fibromyalgia, diabetes, heart failure, chronic kidney disease, and vascular dementia. She was severely cognitively impaired, nonverbal, and required total assistance for all care. Despite these needs, the care plan did not address behaviors such as scratching, which was noted during the incident. The nurse aide's decision to leave the resident unattended in the shower room without supervision or a call for assistance contributed to the incident. Interviews and documentation revealed inconsistencies in the reporting and assessment of the resident's condition before and after the incident. The nurse aide initially reported no skin issues, but later noted skin alterations after the shower. The facility's response included multiple interviews and assessments, but the initial lack of supervision and failure to follow proper procedures in the shower room were critical factors leading to the resident's injuries.
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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