Valley Nursing And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Taylorsville, North Carolina.
- Location
- 581 Nc Highway 16 South, Taylorsville, North Carolina 28681
- CMS Provider Number
- 345247
- Inspections on file
- 20
- Latest survey
- January 8, 2026
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Valley Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
A resident assessed as unable to self-administer medications was found with multiple pills and a liquid medication left at the bedside without nursing supervision. Nursing staff left the medications at the resident's request, unaware of the assessment status, resulting in a failure to follow professional standards for safe medication administration.
A medication error rate above 5% was identified when a nurse administered carvedilol to a resident without checking required blood pressure and heart rate parameters and failed to give ordered folic acid. The nurse overlooked the medication orders, and the electronic system did not enforce the necessary checks, resulting in two errors out of 26 opportunities.
Controlled substances, including lorazepam and morphine, were found stored in an unlocked box inside an unlocked refrigerator in the main medication room. The DON confirmed the box should always be locked, and a nurse admitted to forgetting to lock it after a medication count. The Administrator expected all controlled substances to be locked at all times.
A Wound Nurse failed to change gloves and perform hand hygiene between treating two separate wounds on a resident, contrary to facility policy. The nurse acknowledged the lapse, and facility leadership confirmed awareness of the incident and their expectations for proper infection control practices.
A resident with severe cognitive impairment and an indwelling urinary catheter was discharged without a completed discharge summary, missing the home health provider's information, and without documented or provided education on catheter care to the resident's representative. The representative did not receive necessary instructions or paperwork and had to seek information independently until home health services began.
A resident with a history of gastrointestinal bleeding and an allergy to aspirin was not properly managed after a fall resulting in fractures. The facility failed to notify the Medical Director of the resident's condition and the family's concerns about anticoagulation therapy. Additionally, a delay in performing a venous doppler study was not communicated to the NP, leading to the resident's transfer to the ED where extensive DVT was diagnosed.
A resident with a history of gastrointestinal bleeding and recent fractures experienced neglect when the facility failed to notify the Medical Director about their aspirin allergy and need for anticoagulation. Despite increased pain and swelling indicative of DVT, the facility did not seek timely medical attention, delaying necessary treatment. The resident was later hospitalized with extensive DVT in both lower extremities.
A resident with a history of fractures and anticoagulation therapy experienced increased leg swelling and pain, indicative of DVT. Despite worsening symptoms, the facility delayed seeking emergent medical attention, as a venous doppler study could not be scheduled promptly. The resident was eventually transferred to the hospital, where she was diagnosed with extensive DVT in both legs.
A resident with a history of gastrointestinal bleeding and recent fractures was not properly managed for anticoagulation therapy due to a lack of communication between the NP and the Medical Director. The NP ordered aspirin, which was discontinued due to an allergy, and failed to consult the Medical Director directly. The resident developed signs of DVT, and a delayed doppler study led to hospitalization for blood clots in both legs.
A resident with a history of fractures experienced increased pain and swelling in her left leg, which was not effectively managed by the LTC facility. Despite severe pain levels and a care plan in place, the facility failed to administer prescribed pain medication consistently. The resident's condition worsened, leading to a hospital transfer where she was diagnosed with extensive deep vein thrombi.
A facility failed to report an allegation of neglect to the state survey agency after being notified by a State Surveyor. Despite the requirement to file a 2-hour, 24-hour, and 5-day investigation report, these were not completed. Interviews revealed confusion and miscommunication among staff, with the Assistant Administrator and Director of Clinical Operations believing a report was unnecessary. The Administrator, responsible for filing, was unavailable for comment.
A nurse in a long-term care facility failed to respond appropriately to a resident's cardiac arrest, unable to locate the crash cart or call 911, resulting in the resident's death. Despite completing orientation, the nurse did not demonstrate competency in emergency procedures, leading to immediate jeopardy concerns.
A resident who was a full code experienced agonal breathing and went pulseless, but the facility staff failed to initiate CPR immediately. The staff did not use the overhead paging system or activate EMS promptly. Once CPR was recognized as necessary, the AED was not used, and the crash cart's oxygen tank was inadequate. The resident, admitted with a hip fracture and moderately cognitively impaired, was found unresponsive after returning from a doctor's appointment. Despite vital signs being taken, CPR was delayed, and the resident was pronounced deceased.
A ventilator-dependent resident in an LTC facility experienced a fever, elevated heart rate, and increased respiratory rate, meeting criteria for the sepsis protocol. However, the protocol was not initiated by the nursing staff, who also delayed administering fever-reducing medications and rechecking vital signs. The resident's condition worsened, leading to a hospital transfer and diagnosis of sepsis, UTI, and dehydration. Staff interviews revealed confusion and lack of adherence to the sepsis protocol.
A LTC facility failed to maintain accurate controlled substance records and administered medication from a mislabeled bottle. One resident's hydrocodone/acetaminophen count was incorrect, another's Tramadol record had repeated entries, and a third received Donepezil from a bottle labeled for someone else. The DON acknowledged the need for staff re-education on medication management.
The facility failed to manage medications properly, with loose and unidentified tablets found in a medication cart, expired medications present, and improper storage of inhalation solutions and Tuberculin PPD. Staff were unaware of correct procedures, and an agency nurse admitted to not being oriented to the facility's processes, contributing to these deficiencies.
The facility failed to follow its policies on abuse and neglect by hiring a Dietary Aide with a pending abuse allegation and not reporting abuse and neglect cases within required timeframes. The HR Director overlooked the aide's pending allegation due to personal connections, and the Administrator delayed reporting an abuse allegation. Additionally, local law enforcement was not notified of a confirmed neglect case, contrary to policy requirements.
A resident admitted with a pressure ulcer and indwelling catheter did not have a baseline care plan developed. Despite an admission assessment by a nurse indicating these conditions, a review showed no baseline care plan was completed. Interviews with staff revealed confusion over responsibilities, with the admitting nurse unsure if the plan was completed and the DON confirming its absence.
A resident was discharged without a complete discharge summary, lacking a recapitulation of stay and necessary signatures. The discharge summary was not finalized until weeks later, despite expectations for thorough completion at the time of discharge. Interviews with staff, including the DON and Assistant Administrator, confirmed the deficiency.
A resident dependent on tube feeding was not administered the correct nutritional supplement as per the physician's order. The resident's tube feeding was set at 55 ml/hr instead of the prescribed 60 ml/hr, with incorrect water flush settings. This discrepancy occurred after the resident's readmission from a hospital stay, where the tube feeding rate differed. The facility failed to update the settings to match the physician's order, as confirmed by the nursing staff and DON.
The facility failed to adhere to infection control protocols, with staff not properly donning PPE and neglecting hand hygiene. A nurse aide and an activity assistant did not wear the required N95 masks and eye protection when entering rooms under Special Droplet Precautions for COVID-19. Additionally, a wound nurse did not perform hand hygiene after glove removal during a dressing change. These actions were contrary to the facility's infection control policies.
A facility failed to ensure a Dietary Aide had no pending abuse allegations on the North Carolina Nurse Aide Registry. The HR Director overlooked the pending allegation due to the aide being the DON's son. The aide, who had no resident contact, was terminated after the Administrator was informed of the pending allegation.
A resident with dementia was discharged from a facility after eloping, but the Regional Ombudsman was not notified. The resident was admitted for short-term respite care, and the facility determined it could not meet the resident's needs. The Admissions Coordinator, who typically did not handle discharges, informed the family but not the Ombudsman. The Social Worker was on vacation, and the Assistant Administrator mistakenly believed notification was unnecessary.
A facility failed to provide physician-ordered wound care over a weekend for a resident with arterial ulcers, due to confusion among agency nurses about wound care responsibilities. Additionally, a nurse did not remain with a resident unable to self-administer medications, leading to incomplete medication administration. The facility's protocol required nurses to stay with residents until all medications were taken, which was not followed in this instance.
A resident with a stage 3 sacral pressure ulcer did not receive physician-ordered treatment over a weekend, as documented in the TAR. The facility's protocol required hall nurses to perform wound care on weekends, but agency nurses on duty did not complete the treatment, believing a wound nurse was assigned. This resulted in the treatment not being administered as ordered.
A cognitively impaired resident with a history of wandering exited a facility through a window, despite having a wander guard alarm. The resident was found outside by an Activities Assistant and was returned to the facility with a minor knee abrasion. Staff interviews revealed that the resident had been exhibiting exit-seeking behaviors, and the wander guard alarm only prevented door exits, not window exits.
Two residents with feeding tubes in an LTC facility did not receive the correct water flushes as ordered by their physicians due to incorrect feeding pump settings. One resident's pump settings were blank, and the nurse was unaware of how to program it, while another resident's pump was set to flush every 2 hours instead of every hour. The DON confirmed the errors, and both residents were at risk for dehydration.
Failure to Follow Professional Standards for Medication Administration
Penalty
Summary
A resident admitted with respiratory failure and generalized muscle weakness was assessed as unable to self-administer medications, as documented in the self-medication assessment. Despite this assessment, an observation revealed that the resident had multiple pills and a cup of liquid medication left at the bedside within reach, without nursing supervision. The resident stated familiarity with the medications and indicated that the nurse would leave the medications for self-administration, returning later to collect the empty cups. The resident also expressed a preference to take medications independently and did not require observation. Nurse interviews confirmed that medications were left at the bedside at the resident's request, and the nurse was unaware of the resident's assessment status regarding self-administration. The nurse acknowledged that medications should not have been left unattended. The Director of Nursing confirmed that the resident had been assessed as unable to self-administer medications and that the nurse should not have left the medications at the bedside. The administrator also confirmed that the resident should not have had medications left for self-administration, as per the assessment.
Medication Error Rate Exceeds Acceptable Threshold Due to Nurse Oversight
Penalty
Summary
A medication error rate of 7.69% was identified during a medication pass observation, exceeding the acceptable threshold of less than 5%. Specifically, two medication errors occurred out of 26 opportunities for one resident with hypertension. The first error involved a nurse administering carvedilol, a medication with specific parameters requiring blood pressure and heart rate assessment prior to administration, without performing these assessments. The nurse did not notice the parameters attached to the order and administered the medication without obtaining the necessary vital signs. The second error occurred when the same nurse failed to administer folic acid as ordered for the resident. The nurse stated she overlooked the folic acid order. Interviews with the nurse, the nurse practitioner, and the DON confirmed awareness of these errors. The DON noted that the electronic system did not enforce the required parameters for carvedilol, which contributed to the error, but also stated that the nurse should have checked each medication order more carefully.
Controlled Substances Not Secured Under Double Lock in Medication Room
Penalty
Summary
Surveyors observed that controlled substances, specifically four bottles of liquid lorazepam and two bottles of liquid morphine, were stored in an unlocked box inside an unlocked refrigerator in the main medication room. The Director of Nursing (DON) confirmed that the box containing these controlled substances should always be locked, and Nurse #2, who had the key, acknowledged that she had forgotten to lock the box after counting the medications with the third shift nurse earlier that morning. The Administrator stated that her expectation was for all controlled substances to be locked at all times, whether stored in the medication cart or refrigerator. This failure to secure controlled substances under a double lock in the medication room was directly observed and confirmed through staff interviews, constituting a deficiency in the facility's medication storage practices.
Failure to Follow Hand Hygiene Protocol During Wound Care
Penalty
Summary
A deficiency was identified when the Wound Nurse failed to follow the facility's Hand Hygiene policy during wound care for a resident. During an observation, the Wound Nurse donned a clean gown and gloves, removed the old dressing from the resident's left hip, sanitized her hands, and donned new gloves before cleaning the wound. However, after treating the left hip wound, the Wound Nurse did not remove her gloves or perform hand hygiene before proceeding to treat a second wound on the resident's right ankle. She applied skin prep to the right ankle while still wearing the same gloves used for the previous wound. The facility's policy requires hand hygiene and glove changes before moving from a soiled body site to a clean body site on the same resident. The Wound Nurse acknowledged during an interview that she did not sanitize her hands or change gloves between the two wound sites, attributing the lapse to being distracted by activity in the room. The Director of Nursing and Infection Preventionist confirmed awareness of the incident and stated their expectation for staff to follow infection control best practices. The Administrator also indicated that the Hand Hygiene policy should have been followed during wound care.
Incomplete Discharge Summary and Lack of Catheter Care Education
Penalty
Summary
The facility failed to complete a comprehensive discharge summary for a resident with a history of stroke and neuromuscular bladder dysfunction, who was discharged with an indwelling urinary catheter. The discharge summary was left incomplete, lacking the name and contact information of the home health company responsible for post-discharge care. The social services section did not document the home health provider, and the summary remained in progress at the time of review. The resident was discharged home without this critical information being finalized in the record. Additionally, the facility did not provide or document education regarding catheter care to the resident's representative prior to discharge. Interviews revealed that the nurse responsible for the discharge did not deliver formal catheter care education, and the resident's representative confirmed not receiving any such instruction or related paperwork, aside from a medication list and prescriptions. The representative had to independently research catheter care until home health services began. The discharge summary was not updated to reflect the correct home health provider after a change was made, and the summary was not properly closed.
Failure to Notify Medical Director and Delay in Diagnostic Testing
Penalty
Summary
The facility failed to notify the Medical Director of a resident's documented allergy to aspirin and the family's concern about the lack of anticoagulation therapy following a fall that resulted in multiple fractures. The resident, who had a history of gastrointestinal bleeding, was discharged from the hospital without an anticoagulant prescription despite receiving subcutaneous heparin injections during the hospital stay. The resident's Responsible Party (RP) expressed concerns to the Director of Nursing (DON) about the absence of anticoagulation therapy, but the facility did not take appropriate action to address these concerns. On 12/11/2024, the Assistant Director of Nursing (ADON) was informed by the Nurse Practitioner (NP) to contact the Medical Director for further direction regarding anticoagulation, but this was not done. The NP initially ordered aspirin, which was later discontinued due to the resident's allergy. The resident experienced increased pain and swelling in the left lower extremity, indicative of a potential deep vein thrombosis (DVT), but the facility failed to notify the NP that a venous doppler study could not be completed until the following week. This delay in communication and action resulted in the resident being transferred to the Emergency Department (ED) on 12/28/2024, where extensive DVT was diagnosed. Interviews with facility staff revealed a lack of communication and follow-up regarding the resident's condition and the necessary medical interventions. The Medical Director was not informed of the resident's condition or the delay in diagnostic testing, which could have prompted earlier intervention. The NP was also not made aware of the delay in the venous doppler study, which could have influenced the decision to send the resident to the ED sooner. This series of inactions and communication failures contributed to the deficiency identified in the facility's care of the resident.
Removal Plan
- All licensed nurses, medication aides, and certified nursing assistants were educated by the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) on requirement to notify physician of all significant changes in condition to ensure timely treatment or transfers.
- Licensed nurses, medication aides and certified nursing assessments who are newly hired, including agency, will receive in-service prior to working their initial shift.
- Director of Nursing and/or Staff Development coordinator will be responsible to ensure education is received.
- Ordered studies should be scheduled same day of order.
- If vendor is unable to perform study on same day of order, provider is to be notified by licensed nurse of expected date of study.
- New orders from medical providers given to address changes in condition should be implemented on day of order, unless otherwise noted by provider. If orders are unable to be implemented timely, provider must be made aware immediately in order to ensure any new intervention or transfer is then implemented timely.
- Licensed nurse is to document notification and any new orders, to include transfer to hospital, deemed necessary by medical provider.
- Physician or physician extender is to be made aware by licensed nurse of all residents with aspirin allergy to determine any needs for anticoagulation. This notification to occur upon admission or readmission with any newly identified aspirin allergy.
- Certified nursing assistants and medication aides who identify changes in condition should notify licensed nurse.
Neglect in Addressing Resident's Medical Needs
Penalty
Summary
The facility failed to protect a resident's right to be free from neglect by not notifying the Medical Director about a resident's documented allergy to aspirin and the need for anticoagulation therapy. The resident had a history of gastrointestinal bleeding, a recent fall with fractures, and new immobility. Despite the family's concerns expressed to the Director of Nursing, the Nurse Practitioner did not communicate with the Medical Director for guidance on anticoagulation, leading to a lack of appropriate medical intervention. The resident experienced increased pain and swelling in the left lower extremity, indicative of a potential blood clot, which the facility failed to address promptly. On a specific date, the resident showed signs of deep vein thrombosis (DVT), including increased edema and a positive Homan's sign. Despite these symptoms, the facility did not seek emergent medical attention when a venous doppler study could not be scheduled for several days, delaying necessary medical evaluation and treatment. The resident was eventually transferred to the hospital at their request, where they were diagnosed with extensive DVT in both lower extremities and required hospitalization and anticoagulation therapy. The facility's deficient practice was identified for one of three residents reviewed for neglect, highlighting a failure to act on significant changes in the resident's condition and to provide timely medical intervention.
Removal Plan
- All residents had skin and pain user defined assessments conducted and documented in the medical record to include interview questions for all interviewable residents, and observation by Director of Nursing, Assistant Director of Nursing, Unit manager or Wound Care Nurse for non-interviewable residents with additional findings addressed and provider notified.
- An audit of all residents noted with significant change in condition assessments completed was conducted by the Director of Nursing and Assistant Director of Nursing to identify any unaddressed new or worsening pain or swelling. Audit of einteract Change in Condition user defined assessments revealed no additional concerns noted.
- The DON, ADON, Staff Development and Unit Managers began education for all licensed nurses, medication aides and certified nursing aides on Abuse and Neglect as it is related to not acting or following up on reported and assessed pain or changes in condition. Nursing staff newly hired, including agency, will receive in-service education prior to working their initial shift. Director of Nursing and/or Staff Development coordinator will be responsible to ensure education is received.
- Abuse and neglect policy was reviewed by Administrator prior to providing staff education, no changes to policy are required.
- The education consisted of the following: Identification of pain via verbal and non-verbal cues, Pharmacological and non-pharmacological interventions for pain and swelling, Failing to act on pain or change in condition is considered neglect, Medical provider must be notified of any changes in condition to include acute pain, Provider orders and interventions must be implemented timely, Changes in condition to include pain should have timely follow up to ensure effectiveness of interventions.
Failure to Address Resident's DVT Symptoms Promptly
Penalty
Summary
The facility failed to seek emergent medical attention for a resident with a recent history of spine and pelvic fractures and anticoagulation therapy prior to admission, who experienced increased leg swelling, pain, and a positive Homan's sign indicative of deep vein thrombosis (DVT). Despite the resident's condition worsening, the facility did not arrange for an immediate venous doppler study, which was ordered but could not be scheduled for at least three days. The resident continued to experience increased swelling, pain, and redness in the left lower extremity and was eventually transferred to the hospital, where she was diagnosed with extensive DVT in both lower extremities. The resident had been admitted to the facility with multiple pelvic fractures, a fracture of the lumbosacral spine, and a history of gastrointestinal bleeding. She was noted to have significant pain and swelling in her left leg, which worsened over time. The resident's responsible party had expressed concerns about the lack of anticoagulation therapy due to the resident's immobility and family history of blood clots. Despite these concerns and the resident's deteriorating condition, the facility did not take timely action to address the potential for DVT. Interviews with facility staff revealed that the resident's condition was known, but there was a lack of urgency in addressing the situation. The resident's responsible party was informed of the delay in obtaining a venous doppler study and initially declined to send the resident to the emergency department. However, the resident's condition continued to worsen, leading to her eventual transfer to the hospital, where she received appropriate treatment for DVT.
Removal Plan
- The Director of Nursing (DON) and Nursing Leadership team, which includes the Assistant Director of Nursing (ADON) and Unit Managers, assessed all current facility residents via a head-to-toe body audit and pain assessment to ensure that no other resident was experiencing pain, leg swelling, or redness with no additional residents identified.
- The DON, ADON, Staff Development (SDC), and Unit Managers began education for licensed nurses, medication aides, and certified nursing assistants on assessing and responding to pain and signs/symptoms of blood clots.
- Licensed nurses, medication aides, and certified nursing assistants newly hired, including agency, will receive in-service prior to working their initial shift.
- Director of Nursing and/or Staff Development coordinator will be responsible to ensure education is received.
- Education included: How to recognize deep vein thrombosis (DVT) is a blood clot, Symptoms: Pain, Swelling, Discoloration, Warmth, Positive Homan's sign, Explaining the seriousness of DVT and how they can be life-threatening to Responsible Party's or families so they can make informed decisions.
- 24-hour report will be reviewed at least five days weekly by the DON, ADON, or a unit manager to identify any residents with leg swelling or pain requiring follow-up from provider.
- The Administrator communicated the responsibility of reviewing 24-hour reports to the DON, ADON, and Unit Managers.
- This credible allegation of immediate jeopardy removal plan was reviewed and approved by an ad hoc QAPI meeting.
- Facility administrator notified DON of responsibility for completion of this credible allegation of immediate jeopardy removal plan.
Failure to Communicate and Collaborate on Anticoagulation Therapy
Penalty
Summary
The facility's Nurse Practitioner (NP) failed to communicate and collaborate with the Medical Director after a resident's Responsible Party (RP) raised concerns about the resident not receiving anticoagulation therapy following a fall that resulted in multiple fractures. The NP ordered aspirin, which was later discontinued due to the resident's allergy and history of gastrointestinal bleeding. Despite instructing the Assistant Director of Nursing (ADON) to consult the Medical Director, the NP did not reach out to the Medical Director herself, leading to a lack of timely intervention. The resident, who had a history of gastrointestinal bleeding and was immobile due to fractures, showed signs of increased pain and swelling in the left lower extremity, indicative of a potential deep vein thrombosis (DVT). The NP evaluated the resident and recommended a venous doppler study, but the study was not available until the following week. The resident's condition worsened, and she was eventually transferred to the hospital, where she was diagnosed with blood clots in both lower extremities and required anticoagulation and hospitalization. The Medical Director was not informed of the resident's condition or the delay in the doppler study. Had the Medical Director been notified, he would have ordered a timely doppler study and potentially initiated anticoagulation therapy. The lack of communication and collaboration between the NP and the Medical Director resulted in a delay in appropriate medical intervention, leading to the resident's hospitalization.
Removal Plan
- The Administrator met with the Medical Director and NP and reviewed the expectations of the MD and NP communicating and collaborating with each other. NP should consult with MD in any circumstance regarding medical management needing a higher level of care or beyond his/her scope of practice.
- The agreement between the providers was reviewed, no changes were made to the provider agreement.
- The NP was educated on when she should consult with the MD based on review of scope of practice and collaborative provider agreement.
- The Medical Director/Senior partner of provider group educated the MD and all attending Physicians and on call that the NP should consult with MD in any circumstance regarding medical management needing a higher level of care or beyond his/her scope of practice defined by the North Carolina Medical Board and North Carolina Board of Nursing.
- The Medical Director informed the Administrator and DON that the MD and NP will have weekly meetings to ensure ongoing collaboration, and the MD will report any results of the meetings to Administrator and DON.
Failure in Pain Management for Resident with Leg Swelling
Penalty
Summary
The facility failed to manage a resident's pain effectively, leading to a significant deficiency in care. The resident, who had a history of multiple pelvic fractures and a gastrointestinal bleed, experienced increased pain and swelling in her left lower extremity starting on December 18, 2024. Despite having a care plan in place that included administering analgesia and notifying a physician if interventions were unsuccessful, the facility did not adequately address the resident's escalating pain and swelling. The resident's pain was documented as severe, reaching levels of 8-9 out of 10 on the pain scale, yet there were lapses in administering the prescribed pain medication. Throughout the period from December 18 to December 28, 2024, the resident's condition worsened, with swelling and redness in the left leg becoming more pronounced. Although the resident was evaluated by the Director of Nursing and a Nurse Practitioner, and a venous doppler study was ordered, there was a lack of timely and effective pain management. The resident's pain assessments indicated severe pain, but there were instances where the prescribed PRN pain medication was not administered, and the source of pain was not consistently identified or addressed. On December 28, 2024, the resident's condition had deteriorated to the point where she requested to be sent to the hospital. Emergency Medical Services were called, and upon arrival, they noted the resident's severe pain and elevated blood pressure. The resident was subsequently transferred to the hospital, where she was diagnosed with extensive deep vein thrombi in both legs. The facility's failure to manage the resident's pain and swelling effectively, despite clear signs of distress and a care plan in place, constitutes a significant deficiency in the standard of care provided.
Failure to Report Allegation of Neglect
Penalty
Summary
The facility failed to report an allegation of neglect to the state survey agency concerning a resident. The neglect was brought to the attention of the Administrator, Assistant Administrator, and Regional Nurse Consultant by a State Surveyor. Despite this notification, the facility did not file the required Initial Allegation Report with the state survey agency. Interviews with the Assistant Director of Nursing (ADON) and the Director of Nursing (DON) revealed uncertainty and acknowledgment that the report had not been filed as required. The DON confirmed that the facility was obligated to file a 2-hour report, a 24-hour report, and a 5-day investigation report, but these were not completed. Further interviews with the Assistant Administrator and the Director of Clinical Operations indicated a misunderstanding or miscommunication regarding the necessity of filing the report. The Assistant Administrator believed a report was unnecessary because the resident or their responsible party had not voiced concerns of neglect directly to the facility. The Director of Clinical Operations stated that since the state was already aware of the allegation and an abatement plan was written, there was no need to report it. The Administrator, who was responsible for filing the report, was unavailable for an interview, leaving the deficiency unaddressed at the time of the survey.
Nurse's Incompetence in Emergency Response Leads to Resident's Death
Penalty
Summary
The facility failed to ensure that a nurse was competent in responding to medical emergencies and activating emergency procedures with emergency medical services (EMS). This deficiency was identified when a resident, who was a Full Code, experienced sudden cardiac arrest. Nurse #3 was unable to locate the crash cart and the automated external defibrillator (AED), and did not immediately call 911. As a result, the resident was pronounced deceased by EMS. The investigation revealed that Nurse #3 had completed the facility's orientation process, which included knowledge of the location of the crash cart and emergency procedures. However, during the emergency, Nurse #3 failed to demonstrate this knowledge. The Staff Development Coordinator confirmed that all staff were required to attend an in-person orientation, which included a facility tour and the location of crash carts. Despite this, Nurse #3 was unable to locate the necessary emergency equipment or respond appropriately during the incident. Interviews with the Director of Nursing and the Administrator highlighted concerns about Nurse #3's actions during the emergency. The Director of Nursing noted that there were issues with Nurse #3 not acting sooner and recognizing the need for emergency intervention. The Administrator expressed that Nurse #3 should have remained with the resident, performed ongoing assessments, called 911, and initiated CPR. The facility identified this as an immediate jeopardy situation, indicating a high likelihood of causing serious harm to other residents.
Removal Plan
- The center Administrator notified the Director of Nursing of immediate implementation of Mock Code Drills increasing from Quarterly to Monthly.
- Agency staff receive an abbreviated orientation that includes location of crash carts and emergency process.
- The center orientation process includes emergency equipment location and emergency process.
- The Director of Nursing informed the Staff Development Coordinator that it is her responsibility to orient new hires and new agency staff.
- The Director of Nursing and Nursing Leadership Team initiated education for all licensed nurses and Respiratory Therapy on Assessing and Responding to Changes in Condition to include abnormal vital signs.
- Education was completed for all staff on how and when to call a Code Blue, Calling 911, and the Location of Crash Carts/Emergency Supplies.
- The Regional Nurse initiated education with all staff to include Administrative Staff, Maintenance, Dietary, Laundry, Housekeeping, Nurses' Aides and Therapy Staff on the Location of the Crash Carts/Emergency Supplies, how to call Code Blue.
- No staff shall work until they have received this education.
- The Director of Nursing is responsible for making sure all receive the above education.
- Director of Nursing informed the Staff Development Coordinator that she would be responsible for new hire and new agency education on the above, as well as responsible for verifying competencies and understanding of training.
- Education will be included in new hire orientation and new agency orientation via in person review by a member of the Nurse Management Team.
- No Licensed Nurses, Respiratory Therapists shall work until they have received the above education.
- SDC will verify the competency and understanding of emergency procedures and their role in an emergency.
- A new process was implemented by the Director of Nursing that will include validation of new hire and new agency staff orientation to emergency procedures, crash cart locations, and procedures for calling Code Blue and 911 via a post test administered following orientation.
Failure to Initiate Timely CPR and Use Emergency Equipment
Penalty
Summary
The facility failed to immediately initiate Cardiopulmonary Resuscitation (CPR) for a resident who was a full code and exhibited agonal breathing and went pulseless. The staff did not utilize the overhead paging system to call for assistance or activate Emergency Medical Services (EMS) promptly. Once the need for CPR was recognized by the Respiratory Therapy, they did not implement the use of the Automated External Defibrillator (AED) and lacked an oral airway. Additionally, the regulator on the emergency oxygen tank on the crash cart was inadequate, only reaching 10 liters per minute. The resident involved was admitted with a diagnosis of a fracture of the right femur and post right periprosthetic hip fracture. The resident was moderately cognitively impaired and had a physician's order indicating they were a full code, meaning they wanted to receive CPR. On the day of the incident, the resident returned from a doctor's appointment and was reported to have vomited green fluid. Later, the resident was found unresponsive, and despite having vital signs taken, CPR was not initiated immediately. The resident's oxygen saturation dropped significantly, and CPR was eventually started, but the resident was pronounced deceased. Interviews with staff revealed a lack of coordination and prompt action during the emergency. Nurse #3, who was initially responsible, did not initiate CPR and was reportedly panicked and unsure of what to do. The crash cart was not utilized effectively, and there was confusion about the location and use of emergency equipment. The delay in initiating CPR and the lack of proper equipment and response contributed to the resident's death. The facility's failure to adhere to established emergency procedures and guidelines was evident in this incident.
Removal Plan
- The Director of Nursing and the Assistant Director of Nursing completed an audit of the center's three Crash Carts to ensure they were adequately supplied and in working order.
- The center's policy was reviewed by the IDT and medical director, indicating that the center will perform BLS level CPR.
- The Director of Nursing validated that all three crash carts have emergency oxygen tanks that go to 15 liters.
- The Administrator and Medical Director decided to remove the AEDs from the center and placed a note on each crash cart indicating that the AEDs are no longer in use.
- The center HR Director reviewed all current staff and agency staff CPR certification to ensure they were current.
- The center HR Director and/or the Assistant Administrator verifies agency staff are CPR certified upon their assignment to the center.
- The center Administrator notified the Director of Nursing of immediate implementation of Mock Code Drills increasing from Quarterly to Monthly.
- The Director of Nursing and Nursing Leadership Team initiated education for all licensed nurses and Respiratory Therapy on assessing and responding to changes in condition, including abnormal vital signs.
- Education included review of the center CPR policy, how and when to call a Code Blue, when to call 911, immediate initiation of CPR in cardiopulmonary arrest, and the location of Crash Carts/Emergency Supplies.
- The Regional Nurse initiated education with all staff on the location of the Crash Carts/Emergency Supplies, how to call Code Blue, and to notify a nurse with any noted change in a resident condition.
- Education included the Nurse's Aides responsibility in alerting licensed staff immediately of abnormal vital signs and/or unresponsive residents.
- No staff shall work until they receive this education.
- Director of Nursing is responsible for making sure all receive the above education.
- Director of Nursing informed the Staff Development Coordinator that she would be responsible for new hire and new agency education on the above.
- Night shift charge nurses are responsible for checking the crash carts nightly to ensure they are appropriately stocked.
- ADON or DON will check the crash carts weekly to ensure they are appropriately stocked and in working order.
Failure to Initiate Sepsis Protocol for Ventilator-Dependent Resident
Penalty
Summary
The facility failed to assess a resident and initiate the sepsis protocol when a ventilator-dependent resident was found to have a fever, elevated heart rate, and increased respiratory rate. Nurse #1 did not initiate the sepsis protocol despite the resident meeting two criteria on the Ventilator Unit Sepsis Protocol. The nurse also failed to re-check the resident's temperature for the remainder of the shift and did not administer fever-reducing medication. The resident's condition worsened overnight, with a significant increase in temperature and heart rate by the next morning. Nurse #2, who took over the care of the resident, was informed of the elevated temperature and heart rate but delayed administering the prescribed fever-reducing medications. The nurse also failed to recheck the resident's temperature in a timely manner after administering the medication. The Unit Manager later prompted the nurse to check the temperature, which remained elevated. The sepsis protocol was eventually initiated, and the resident was transferred to the emergency department, where they were diagnosed with sepsis, a urinary tract infection, an infected sacral wound, and dehydration. Interviews with staff revealed a lack of understanding and adherence to the sepsis protocol. Nurse #1 did not initiate the protocol because the resident was already on antibiotics, and Nurse #2 was unaware of the protocol's existence. The Medical Director stated that the protocol should be initiated by a physician or nurse practitioner, while the Nurse Practitioner indicated that any nurse could initiate it. This confusion contributed to the delay in appropriate care for the resident, leading to their transfer to the hospital in critical condition.
Removal Plan
- The Director of Nursing (DON) and Nursing Leadership team obtained vital signs of all current residents to ensure no other resident was experiencing an acute change in condition.
- The Staff Development Coordinator (SDC) initiated education for all licensed nurses and Respiratory Therapists on the Facility Sepsis Protocol, assessing and responding to changes in condition, notifying the provider, and reassessment for efficacy after initial intervention.
- Licensed nurses educated on the new process for monitoring vital sign exception report at the end of every shift and entering their vital signs every shift as ordered.
- Nurses' Aides educated on vital signs and reporting abnormal results immediately to the charge nurse.
- No licensed staff shall work until they have received this education.
- Director of Nursing responsible for ensuring all receive the above education.
- Education will be included in new hire orientation and new agency orientation via in-person review or a written education packet.
- A new process implemented by the Director of Nursing to monitor resident vital signs exception report at the end of shift daily to ensure abnormal vital signs were addressed timely.
- Unit Managers will round on their residents daily to ensure no evidence of change in condition, including abnormal vital signs.
- If Unit Manager is not present, the ADON, DON, or Shift Supervisor will complete the rounds on that unit.
Medication Management Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain an accurate account of controlled substances for three residents, leading to discrepancies in medication records and administration. Resident #90 was prescribed hydrocodone/acetaminophen for pain management, but the medication administration record showed no doses were given, despite a declining count on the controlled drug record. The discrepancy in the count was unexplained, and the medication remained on the cart months after discontinuation. The consultant pharmacist was unaware of the issue, and the Director of Nursing (DON) acknowledged the need for staff re-education. Resident #110's controlled drug record for Tramadol showed repeated entries, resulting in an incorrect count of remaining tablets. The nurse responsible for the resident did not notice the discrepancy during her shift, and the Unit Manager was unable to explain the error. The consultant pharmacist suggested that the DON educate the nurses on proper documentation practices. The DON confirmed that discrepancies should be reported immediately, but the issue was not identified until the surveyor's intervention. Resident #113 was administered Donepezil from a bottle labeled for another person. The medication was brought from home by the resident's family, and the admission nurse failed to verify the labels. The Unit Manager and consultant pharmacist both indicated that the medication should have been checked against the resident's orders. The DON confirmed that the admission nurse should have ensured the medications were correctly labeled for Resident #113.
Medication Management Deficiencies
Penalty
Summary
The facility failed to properly manage and store medications across several medication carts, leading to multiple deficiencies. On the 300 Hall Bottom medication cart, five loose and unidentified tablets were found, and the medication aide was unable to identify them, attributing the responsibility to the third shift nurses. Additionally, the same cart contained ipratropium bromide/albuterol sulfate inhalation solutions not stored according to the manufacturer's instructions, as they were removed from their protective foil pouches. The medication aide was unaware of the correct storage procedure, indicating a lack of knowledge and training. On the 600 Hall medication cart, several expired medications were found, including Divalproex, Atorvastatin, Ascorbic Acid, Donepezil, and Venlafaxine. An open and undated vial of Tuberculin Purified Protein Derivative (PPD) was also discovered, which should have been refrigerated and discarded after thirty days. Nurse #5 admitted to using medications brought from home for a resident in respite care without checking expiration dates, and the Unit Manager confirmed that the admission nurse should have verified the medications' validity. The Consultant Pharmacist, who reviews medication carts periodically, stated that expired medications are usually not an issue, suggesting a lapse in the regular review process. Furthermore, Nurse #6, an agency nurse, admitted to not being oriented to the facility's admission process and placed a bag of medications brought by a resident's family into the medication cart without reviewing them. This lack of orientation and oversight contributed to the presence of expired medications. The Director of Nursing acknowledged that nurses are expected to check their medication carts daily for expired or discontinued medications, but this protocol was not followed, leading to the deficiencies observed during the survey.
Failure to Follow Abuse and Neglect Reporting Policies
Penalty
Summary
The facility failed to adhere to its Abuse, Neglect, and Exploitation policy by hiring a Dietary Aide (DA) with a pending allegation of abuse on the North Carolina Nurse Aide Registry. The Human Resources (HR) Director did not thoroughly review the registry report due to the DA being the Director of Nursing's (DON) son. The DA was hired and worked several shifts before the pending allegation was discovered, leading to his immediate termination. The HR Director acknowledged the oversight and confirmed that the DA had no resident contact during his employment. The facility also failed to report an abuse allegation involving a resident within the required timeframe. The Administrator was informed of the allegation on a specific date but delayed reporting it to the Division of Health Service Regulation (DHSR) and law enforcement. The initial report was submitted two days later, and the Administrator admitted the delay was due to gathering statements and details, which caused time to slip away. Additionally, the facility did not notify local law enforcement of a confirmed neglect case involving another resident. The neglect was substantiated by Adult Protective Services (APS) due to omissions in wound treatment documentation. The Assistant Administrator completed the initial report but failed to inform law enforcement, and the Administrator was unaware that the report was submitted as resident neglect. The facility's policy required immediate reporting to law enforcement, which was not followed in this case.
Failure to Develop Baseline Care Plan for Resident with Pressure Ulcer and Catheter
Penalty
Summary
The facility failed to develop a baseline care plan for a resident who was admitted with a pressure ulcer and an indwelling catheter. The resident, who had a diagnosis of pressure ulcer of the sacral region and neuromuscular dysfunction of the bladder, was admitted on a specified date and discharged on another. The admission assessment completed by Nurse #7 indicated the presence of multiple pressure ulcers and an indwelling catheter. However, a review of the medical record revealed that no baseline care plan was completed for the resident. Interviews with staff, including MDS Nurse #1 and Nurse #7, highlighted a lack of clarity and follow-through in the process of developing baseline care plans. MDS Nurse #1 stated that the nurse admitting the resident was responsible for initiating the baseline care plan, with the next shift completing any unfinished tasks. Nurse #7, who admitted the resident, believed he had completed the baseline care plan but could not confirm due to lack of access to the medical record. The Director of Nursing confirmed that no baseline care plan was developed for the resident, noting that the facility had only recently begun utilizing baseline care plans as of January 2024.
Incomplete Discharge Summary for Resident
Penalty
Summary
The facility failed to complete a comprehensive discharge summary for a resident who was cognitively intact and discharged to her home. The discharge summary, titled CCH Bridge to Home Discharge Summary - v2, was dated the day of discharge but lacked a complete recapitulation of stay. Additionally, it was not signed by the resident or her representative, and several sections, including social services, nursing services, recapitulation of stay, and discharge instructions/follow-up precautions, were not completed until several weeks after the discharge. Interviews with facility staff revealed that the hall nurses were responsible for opening and filling out the discharge summary on the day of discharge, while other service areas completed their respective sections. The nurse assigned to the resident at the time of discharge was expected to print the discharge summary and provide the resident with paper prescriptions and medication education. However, the Director of Nursing and the Assistant Administrator confirmed that the discharge summary was not completed thoroughly at the time of discharge, and the reason for this oversight was unknown.
Failure to Administer Tube Feeding Per Physician's Order
Penalty
Summary
The facility failed to administer a high protein, fiber-fortified nutritional supplement per the physician's order for a resident who was dependent on tube feeding. The resident, who had multiple diagnoses including dysphagia and dependence on a respirator, was supposed to receive tube feeding at a rate of 60 ml/hr with 20 cc water flushes every hour. However, observations revealed that the tube feeding was set at 55 ml/hr with water flushes at 30 ml/hr, which was not in accordance with the physician's order. This discrepancy was confirmed by both the nursing staff and the Director of Nursing (DON), who acknowledged that the settings should have been checked and adjusted to match the physician's order. The issue arose when the resident was readmitted to the facility following a hospitalization, during which the tube feeding rate was set at 55 ml/hr. Upon readmission, the facility reinstated the previous order of 60 ml/hr but failed to update the settings accordingly. Interviews with the Registered Dietitian (RD) and the Assistant Administrator revealed that the nursing staff did not clarify the tube feeding order upon the resident's return, leading to the continued use of the incorrect settings. The oversight was attributed to distractions and a lack of communication between the hospital and the facility regarding the correct tube feeding rate.
Infection Control Deficiencies in PPE and Hand Hygiene
Penalty
Summary
The facility failed to adhere to proper infection prevention and control protocols, specifically in the use of Personal Protective Equipment (PPE) and hand hygiene. During observations, it was noted that a nurse aide did not don the required N95 mask before entering a resident's room under Special Droplet Precautions for COVID-19. The aide initially entered the room with only a gown and gloves, later realizing the omission of the N95 mask, which she then donned over her personal face mask. Additionally, the aide did not remove the N95 mask upon exiting the room, only removing it later in a different location. Similarly, an activity assistant also failed to don eye protection and did not remove the N95 mask before exiting a resident's room, potentially spreading the virus to other areas. The facility's infection control policy requires staff to don full PPE, including gowns, gloves, N95 masks, and eye protection, when entering rooms of residents with suspected or confirmed COVID-19. However, staff members were observed not following these protocols, with some under the mistaken belief that personal glasses sufficed as eye protection. The Infection Control Nurse and Director of Nursing confirmed that staff should follow the outlined precautions, and the Infection Control Nurse denied advising staff that personal glasses were an acceptable substitute for goggles or face shields. In addition to PPE issues, there was a failure in hand hygiene practices during wound care. A wound nurse did not perform hand hygiene after removing gloves during a dressing change for a resident with a sacral wound. The nurse believed her hands were still clean after glove removal, which contradicted the facility's hand hygiene policy. The Infection Preventionist and Director of Nursing confirmed that hand hygiene should be performed before and after glove removal, emphasizing the importance of using hand sanitizer or washing hands with soap and water.
Failure to Screen Employee for Abuse Allegations
Penalty
Summary
The facility failed to ensure that a staff member, specifically a Dietary Aide, had no pending or substantiated allegations of resident abuse or neglect on the North Carolina Nurse Aide Registry. The Dietary Aide was hired and worked for a brief period before it was discovered that there was a pending allegation of abuse against him on the registry. The HR Director, responsible for conducting background checks and reviewing the registry, overlooked this pending allegation due to the Dietary Aide being the son of the Director of Nursing (DON). The HR Director admitted to not thoroughly reviewing the registry document, which led to the Dietary Aide being employed despite the pending allegation. The Dietary Aide had no direct contact with residents during his employment, as confirmed by the Dietary Manager, who stated that the aide only participated in classroom orientation and worked in the kitchen alongside another aide. The Administrator was informed by an external source about the pending allegation, which prompted an immediate review of the employee file and subsequent termination of the Dietary Aide. The Administrator confirmed that had the pending allegation been known earlier, the aide would not have been allowed to work at the facility.
Failure to Notify Ombudsman of Facility-Initiated Discharge
Penalty
Summary
The facility failed to notify the Regional Ombudsman of a facility-initiated discharge for a resident who was admitted for a short-term respite stay. The resident, who had a diagnosis of dementia and was moderately cognitively impaired, was discharged home after eloping from the facility. The family was contacted by the Admissions Coordinator and informed that the facility could not meet the resident's care needs and would assist in finding a secure unit. However, the Regional Ombudsman was not notified of this discharge. Interviews with facility staff revealed a lack of communication and understanding of responsibilities regarding the discharge process. The Admissions Coordinator, who was instructed to contact the family, typically did not handle discharges, which were usually managed by the Social Worker. The Social Worker was on vacation at the time, and the Business Office Manager, who covered her duties, was not involved in the discharge process. The Assistant Administrator believed that notification to the Regional Ombudsman was not necessary due to the resident's respite care status, which led to the oversight.
Failure to Provide Wound Care and Medication Administration
Penalty
Summary
The facility failed to provide a physician-ordered treatment for an arterial ulcer over a weekend for a resident with wounds. The resident, who was moderately cognitively impaired, had chronic non-pressure ulcers and an infection of the foot, requiring daily treatment with Dakin's solution and foam dressing. However, the Treatment Administration Record (TAR) showed that the treatment was not completed on a Saturday and Sunday, as there were no initials indicating the treatment was done. Interviews with agency nurses who worked those days revealed confusion about the responsibility for wound care, as they were informed that a wound nurse was present, which was not the case. Additionally, the facility failed to ensure a nurse remained at the bedside to confirm medication administration for a resident unable to self-administer medications. The resident, who had hemiplegia and other conditions, was observed taking medications independently without a nurse present, despite not having an order to self-administer. The nurse involved believed the resident had taken all medications before leaving the room, but upon returning, found some pills still in the medication cup. The resident confirmed that nurses usually stayed with him during medication administration, but occasionally they did not. Interviews with the Director of Nursing and Assistant Administrator confirmed that the facility's expectation was for nurses to stay with residents until all medications were taken. The lack of adherence to this protocol resulted in a deficiency in ensuring proper medication administration for the resident.
Failure to Administer Pressure Ulcer Treatment Over Weekend
Penalty
Summary
The facility failed to provide a physician-ordered treatment for a pressure ulcer over a weekend for a resident with a stage 3 sacral pressure ulcer, which had progressed to stage 4. The treatment, which involved applying Dakins solution and covering the wound with calcium alginate and foam dressing, was not documented as completed on two consecutive days. The Treatment Administration Record (TAR) for those days was blank, indicating the treatment was not performed as ordered. Interviews with staff revealed that the responsibility for wound care on weekends was unclear. Agency nurses working on the relevant days stated they did not perform the wound care, believing a wound nurse was assigned. The facility's wound care protocol involved a wound nurse completing dressings Monday through Friday, with hall nurses expected to perform wound care on weekends. However, there was no designated wound care nurse on the schedule for the weekend in question, leading to the treatment not being administered.
Inadequate Supervision Leads to Resident Elopement
Penalty
Summary
The facility failed to adequately supervise a cognitively impaired resident, leading to an incident where the resident exited the facility through a sliding window in his room. The resident, who had a history of wandering and was identified as being at significant risk of getting to a dangerous place, was able to ambulate independently. Despite having a wander guard alarm placed on his ankle, the alarm only prevented him from exiting through the facility's doors, not through windows. On the day of the incident, the resident was found outside in the unenclosed courtyard by an Activities Assistant, who was alerted by a family member of another resident. The resident was approximately 20-30 feet from a driveway and parking lot, wearing a t-shirt, bathrobe, and socks, and carrying his shoes and a plastic bag with his belongings. The Activities Assistant escorted the resident back inside, where he was assessed by the Wound Nurse for a small abrasion on his knee. Interviews with facility staff revealed that the resident had been exhibiting exit-seeking behaviors shortly after admission, prompting the placement of the wander guard alarm. However, the alarm did not prevent the resident from opening the window and exiting the facility. The Assistant Administrator and Director of Nursing confirmed that the resident had exited through a window, and the facility's initial response included securing the window to prevent further incidents.
Incorrect Feeding Pump Settings for Water Flushes
Penalty
Summary
The facility failed to ensure the correct volume rate settings on feeding pumps for two residents with feeding tubes, as ordered by their physicians. Resident #1, who was admitted with chronic respiratory failure and a gastrostomy tube, had a physician's order for water flushes at a rate of 60 ml every 2 hours. However, observations revealed that the feeding pump settings for water flushes were blank, indicating that the resident did not receive the prescribed water flushes. Nurse #1, who was responsible for the resident during the day shift, admitted to not checking or knowing how to program the feeding pump for water flushes. The Director of Nursing (DON) confirmed the oversight and noted that the resident was dependent on the feeding pump for hydration. Similarly, Resident #2, also with chronic respiratory failure and no oral intake, had a physician's order for water flushes at a rate of 90 ml every hour. However, the feeding pump was incorrectly set to flush every 2 hours. Nurse #3, who worked the night shift, did not review the physician's order to ensure the rate setting was correct and assumed the settings were already properly configured. The DON identified the error during an observation and confirmed the incorrect settings against the physician's order. Interviews with the Registered Dietitian and the Medical Director highlighted the reliance on feeding pump water flushes for hydration in residents unable to receive oral intake. Both residents were at risk for dehydration due to the incorrect feeding pump settings, which were not verified or adjusted by the nursing staff as per the physician's orders. The facility's failure to ensure accurate feeding pump settings for water flushes led to a deficiency in the care provided to these residents.
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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