Wesley Pines Retirement Community
Inspection history, citations, penalties and survey trends for this long-term care facility in Lumberton, North Carolina.
- Location
- 1000 Wesley Pines Road, Lumberton, North Carolina 28358
- CMS Provider Number
- 345180
- Inspections on file
- 19
- Latest survey
- January 30, 2026
- Citations (last 12 mo.)
- 7
Citation history
Health deficiencies cited at Wesley Pines Retirement Community during CMS and state inspections, most recent first.
A resident with chronic constipation and gastroparesis had a provider order for Linzess 290 mcg, one capsule PO daily, but nurses and medication aides instead honored the resident’s request to take three capsules twice weekly. Staff routinely placed the daily capsule into a bedside bottle and, on designated days, removed three accumulated capsules and left them in a med cup for the resident to self-administer, while continuing to document the drug as given daily per order. Multiple nurses and med aides acknowledged they knew this practice did not match the written order yet did not notify the MD, NP, or DON of the resident’s ongoing refusal of the ordered regimen or the altered dosing schedule, and leadership and the NP reported they were unaware of the deviation until it was discovered during survey.
A resident with chronic constipation, paraplegia, and significant contractures, who was assessed as unable to self-administer medications, was ordered Linzess 290 mcg PO daily along with Magnesium Citrate twice weekly and PRN Simethicone. Instead of administering Linzess once daily and observing ingestion, multiple nurses and medication aides routinely placed each day’s Linzess capsule into an empty Simethicone bottle kept at the bedside, then removed three capsules on certain days and left them in a medication cup for the resident to take later according to her personal bowel regimen. The resident reported and demonstrated how she self-administered the three capsules using her mouth, and surveyors observed a cup with three capsules on her bed and found a Linzess capsule stored in the Simethicone-labeled bottle. Staff interviews confirmed this practice had been ongoing for an extended period, that the MAR was signed as if Linzess had been given daily as ordered, and that there was no provider order authorizing the altered dosing schedule or self-administration.
A resident had multiple medications, including Linzess, Biotin, Simethicone, and Clobetasol spray, stored on a bedside table, with some products expired and a Linzess capsule placed in a bottle labeled for Simethicone. Several nurses and medication aides acknowledged routinely placing the Linzess capsule into the bedside bottle at the resident’s request, despite knowing medications should not be stored in resident rooms. On a medication cart, an opened Novolog insulin pen lacked an open date, and an opened Lantus insulin pen remained available for use beyond the manufacturer’s 28-day discard period, even though staff reported they were responsible for checking carts daily and dating and discarding insulin pens appropriately.
Surveyors found that the outside cleaning area near the kitchen exit was unusable due to scattered debris, leaves, and multiple pieces of broken equipment, including a sauna tub, recliner, and metal racks, along with discarded items from maintenance, housekeeping, and dietary. The drain in this enclosed brick area was blocked by leaves and debris, preventing proper drainage when pressure hoses are used to clean kitchen items, wheelchairs, and beds. The DM and Maintenance Director acknowledged that Dietary, Housekeeping, and Maintenance were responsible for keeping this area clean and functional, but it remained cluttered and open to the elements, creating conditions available to pests and rodents.
A nurse failed to follow the facility’s nephrostomy tube care policy during a dressing change for a resident with a nephrostomy tube. After removing the old dressing, discarding soiled items, and removing her gloves, the nurse did not perform hand hygiene before donning sterile gloves and applying a new sterile dressing. Facility policy required handwashing after glove removal and before putting on sterile gloves. In subsequent interviews, the nurse acknowledged forgetting this step, and the IP, NP, and DON all confirmed that hand hygiene should have occurred between removal of the old dressing and application of the new dressing, with the NP noting this lapse put the resident at risk for bacterial introduction to the ostomy site.
A resident with advanced dementia, Parkinson’s disease, severe cognitive impairment, bowel incontinence, and a history of combative behavior during ADLs and prior falls was receiving incontinence care from a NA around mealtime. After an initial brief change during which the resident remained calm, the resident had another bowel movement. When the NA resumed care, the resident began hitting and pinching, prompting the NA to call for assistance via radio. While other staff were occupied, the NA was able to calm the resident and chose to resume incontinence care alone, despite the resident’s known behavioral history. During this care, with the resident turned away from the caregiver, the resident grabbed the metal bed frame, pulled himself off the bed, and fell, striking his head on a dresser and sustaining a forehead laceration that required treatment in the ED. Interviews and documentation confirmed the resident’s established pattern of aggression during care and that only one staff member was present at the time of the fall.
Staff failed to accurately document the administration and refusals of a constipation medication (Linzess) for a resident. Although the physician ordered a daily oral dose on specific days of the week, multiple nurses and medication aides admitted they charted the drug as given on days when it was not administered and was instead left or stored in the resident’s room. One nurse reported the resident had actually been taking three capsules only on two days per week for an extended period, contrary to the daily order. The NP and consulting pharmacist stated they rely on accurate MAR documentation, including refusals, for clinical decision-making, and the DON confirmed the MAR must be accurate at all times.
A staff member at a facility misappropriated a Duragesic pain patch from a resident with chronic back pain. The staff member, who was not scheduled to work, entered the resident's room and took the patch, leading to his own medical distress. The incident was reported to authorities, and the staff member was terminated. The resident did not report any pain or missing doses, and no adverse reactions were noted.
A dependent resident with cognitive impairment and hemiplegia did not receive a breakfast tray due to a nursing assistant forgetting to provide it. The resident required feeding assistance, and the tray was found in the kitchen warmer later in the morning. The DON confirmed the oversight, and the nursing assistant admitted to forgetting without asking for help.
Failure to Notify Provider of Resident’s Long-Term Deviation From Ordered Linzess Regimen
Penalty
Summary
The deficiency involves the facility’s failure to notify the physician when nursing staff were not following a physician’s order for the administration of Linzess for a resident with chronic idiopathic constipation, gastroparesis, and rectal paralysis. The resident was cognitively intact and had a physician’s order for Linzess 290 mcg, one capsule by mouth daily. Review of the Medication Administration Record showed the medication was documented as given daily between 7:00 AM and 11:00 AM. However, during an observation of the resident’s room, three capsules were seen in a medication cup on the bed, and the resident reported these were her Linzess capsules, which she took to help move her bowels. Further interviews revealed that the resident did not take Linzess daily as ordered. Instead, nursing staff and medication aides placed the daily capsule into an empty medication bottle kept at the bedside. On specific days of the week, staff removed accumulated capsules from the bottle and placed three capsules into a medication cup for the resident to take together, in accordance with the resident’s request to take three capsules twice weekly rather than one capsule daily. Multiple staff members, including nurses and medication aides, acknowledged they had been following this practice for an extended period, knew it did not match the written physician order, and did not question or clarify the order. Staff interviews also showed that nurses and medication aides did not notify the physician, nurse practitioner, or DON that the resident was refusing the ordered daily dose and instead taking three capsules twice weekly. Nurses stated they understood they should have notified the provider about the resident’s refusal to take the medication as ordered but instead honored the resident’s request. Medication aides stated they believed it was the nurses’ responsibility to notify the provider and did not escalate the issue, despite recognizing that the administration method did not match the order. The DON and nurse practitioner both reported they had no prior knowledge of this altered dosing regimen and that they first became aware only after the DON was informed during the survey.
Failure to Follow Physician’s Order and Improper Medication Storage for Linzess
Penalty
Summary
The deficiency involves the facility’s failure to follow a physician’s order for administration of Linzess for a resident with chronic idiopathic constipation, gastroparesis, paraplegia, and bilateral upper and lower extremity contractures. The resident had been assessed and determined not to be able to self-administer medications, and her care plan noted a history of refusing medications and care at times based on her personal routine. Despite this, nursing staff and medication aides routinely deviated from the written order for Linzess 290 mcg by mouth daily and instead accommodated the resident’s preferred regimen of taking three capsules twice weekly. The resident reported that staff left three Linzess capsules in a medication cup at her bedside on specific days for her to take later, and she demonstrated how she self-administered them using her mouth due to her hand contractures. Surveyor observations confirmed that a medication cup with three capsules was left on the resident’s bed while she sat in her wheelchair, and that she had significant bilateral hand and wrist contractures. The resident explained that staff placed her daily Linzess capsules into an empty medication bottle labeled for Simethicone kept on her bedside table, and on certain days staff removed three capsules from that bottle, placed them in a medication cup, and left them for her to take at a specific time. The DON later opened the bedside bottle labeled Simethicone and found a Linzess capsule inside. Review of the medical record showed no order from the resident’s gastroenterologist authorizing three Linzess capsules twice weekly, and the current physician’s orders specified a single 290 mcg capsule daily, including Saturdays, as well as Magnesium Citrate twice weekly and Simethicone as needed. Multiple staff interviews revealed that several nurses and medication aides had long been placing the Linzess capsules into the Simethicone bottle at the bedside and allowing the resident to take three capsules on designated days, rather than administering one capsule daily as ordered and observing ingestion. Nurse #1 admitted she had been placing the daily Linzess capsule into the bedside bottle for some time and acknowledged she should not have done so, especially given the resident did not have an order to self-administer medications. Medication Aides #1 and #2 stated they had been trained or told by other nurses to store the Linzess in the bedside bottle and to set out three capsules on the resident’s preferred days, and they acknowledged they did not question the discrepancy with the physician’s order. Another nurse confirmed that the resident had been taking three capsules on two days per week “for as long as she could remember” and that she knew this practice did not follow the written order. In contrast, one night-shift nurse reported she always stayed with the resident until she took the ordered Linzess and refused to leave capsules in the bedside bottle. The Nurse Practitioner and Consulting Pharmacist later confirmed that the dose the resident was actually taking exceeded the recommended maximum daily dose and that the medication should have been administered as prescribed, but there was no documentation in the record authorizing the altered regimen. The facility’s own documentation showed that the Medication Administration Record was being signed to indicate that Linzess was administered daily as ordered, even though staff interviews and resident statements showed that the medication was being stored in a mislabeled bottle at the bedside and taken in a different dose and schedule than prescribed. The resident’s self-administer medication assessment, updated shortly before the survey, continued to show she was not approved to self-administer medications, yet staff left medications in her room and did not consistently remain present to verify ingestion. The DON stated she had no knowledge that staff were leaving Linzess capsules in the Simethicone bottle or that the resident was taking three capsules twice weekly instead of one capsule daily, and she stated she expected staff to follow the five rights of medication administration and the physician’s orders as written.
Improper Medication Storage in Resident Room and Undated/Expired Insulin Pens on Medication Cart
Penalty
Summary
The deficiency involves failure to properly secure, label, and manage medications, including allowing medications to be stored in a resident’s room and maintaining expired medications. One cognitively intact resident had multiple medications stored on her bedside table, including a Simethicone bottle containing a Linzess capsule, two opened Biotin bottles (one with 1,000 mcg tablets and one with 5,000 mcg tablets expired in 04/2024), an opened Simethicone bottle expired in 01/24/2024, and a Clobetasol Propionate 0.05% spray. The Linzess capsule was being placed into an empty Simethicone bottle and left at the bedside, and the resident reported that nursing staff routinely left the daily Linzess capsule in that bottle on her bedside table. Multiple staff interviews confirmed that nurses and medication aides had been placing Linzess capsules into the empty Simethicone bottle and leaving it in the resident’s room at her request, despite knowing medications should not be stored in resident rooms. One nurse acknowledged she had left the Linzess capsule in the Simethicone bottle without realizing the bottle was labeled for a different medication. Two medication aides reported that, over their respective periods of employment, they had routinely placed Linzess capsules into the bottle with the pink cap kept at the bedside. Another nurse stated she was aware that Linzess capsules were being stored in the labeled Simethicone bottle in the resident’s room until administration on specific days and admitted she had placed the capsules there even though she knew residents were not to have medications at the bedside. A separate deficiency was identified on a medication cart, where an opened Novolog insulin pen had no documented open date and an opened Lantus insulin pen remained on the cart past its 11/24/25 expiration date, despite manufacturer instructions to discard 28 days after opening. Observation of the Lantana hall medication cart with a nurse revealed these issues, and the nurse stated that nurses and medication aides were responsible for checking carts daily for expired medications and ensuring insulin pens were dated when opened and discarded when expired. The DON stated her expectation that opened insulin pens be dated so staff could determine if they were still appropriate for use and that expired medications be removed from the cart.
Improper Disposal and Accumulation of Debris in Kitchen Outside Cleaning Area
Penalty
Summary
Surveyors identified a deficiency related to improper disposal and accumulation of garbage, refuse, and broken equipment in the outside cleaning area adjacent to the kitchen exit. During an observation of the kitchen’s outside cleaning area, located approximately four feet from the kitchen exit door, surveyors noted scattered debris and leaves, a broken sauna bathtub, a broken recliner, broken metal racks, and additional discarded items from maintenance, housekeeping, and kitchen departments. The amount of debris and discarded equipment rendered the enclosed brick cleaning area unusable, and leaves and debris were observed blocking the drain that is intended to allow water to drain when pressure hoses are used to clean kitchen items, wheelchairs, and beds. In interviews, the DM stated that Maintenance, Housekeeping, and Dietary were jointly responsible for keeping the outside cleaning area clean and functional, with trash removed so the drain could operate properly during cleaning activities. The DM acknowledged that the area could not currently be used because it was full of discarded broken equipment and debris, and the drain was blocked. A subsequent tour with the Maintenance Director and Administrator confirmed the presence of scattered debris, leaves, broken equipment, and discarded items from multiple departments around the sides and back of the enclosure, which was open to the elements and available to pests and rodents. The Administrator stated an expectation that Maintenance ensure the cleaning area was usable and free of debris and broken facility equipment.
Failure to Perform Hand Hygiene During Nephrostomy Tube Dressing Change
Penalty
Summary
The deficiency involves a failure to follow the facility’s infection prevention and control procedures during nephrostomy tube care for one resident. The facility’s policy for nephrostomy tube dressing changes specifies that after removing the soiled dressing and discarding it, staff must remove gloves, perform hand hygiene, and then don sterile gloves. During an observed nephrostomy tube dressing change for Resident #15, Nurse #3 donned a gown and gloves, removed the old dressing, discarded it, and cleansed the tubing and connection port with alcohol pads. After discarding the soiled items and removing her gloves, Nurse #3 immediately donned sterile gloves without washing her hands, and then applied a new sterile dressing to the nephrostomy tube insertion site. In interviews following the observation, Nurse #3 acknowledged that she should have washed her hands after removing the gloves used to change the old dressing and before putting on sterile gloves, stating she forgot but understood the importance of proper handwashing in infection control. The Infection Preventionist confirmed that hand hygiene should have been performed after removal of the old dressing and prior to donning sterile gloves and described hand hygiene as one of the most important steps in preventing infections. The NP caring for Resident #15 stated that the nurse should have washed her hands between handling the old dressing and applying the new dressing and explained that failure to follow this protocol put the resident at risk for introduction of bacteria to the ostomy site, which could cause infection. The DON stated that nurses changing any dressing should wash their hands before beginning, after removing the old dressing, before applying the new dressing, and after completing the dressing change, and confirmed that Nurse #3 did not follow this process.
Failure to Provide Safe Incontinence Care to Combative Resident Resulting in Fall and Head Injury
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s environment was free from accident hazards and that adequate supervision was provided during incontinence care. The resident involved had multiple significant diagnoses, including Alzheimer’s disease, Parkinson’s disease, history of transient ischemic attack, chronic pain syndrome, essential hypertension, major depressive disorder, orthostatic hypotension, and non‑traumatic brain dysfunction. A quarterly MDS showed he had severely impaired cognitive skills, no recall ability, dependence on staff for all care, bowel incontinence, and an indwelling urinary catheter. He had a history of falls with minor injury and was receiving hospice care, as well as antibiotic, opioid, and antipsychotic medications. The resident’s care plan identified him as at risk for falls related to use of a mechanical lift and documented a history of recurrent falls. A separate behavior care plan identified him as at risk for behavior problems related to dementia and refusal of care or medications, with a history of anxiety, refusal of care, choking a staff member, restlessness, wandering, suicidal ideation, and combative behavior. Specific documented behaviors in the days prior to the incident included swinging his hands with balled fists, grabbing and squeezing staff hands, being combative during incontinence care, grabbing and digging his nails into staff skin, clenching arms and legs to prevent bathing, throwing offered items such as stuffed animals or washcloths to the floor, and hitting a nurse during a pain patch change. Interventions included assisting with self‑care needs, determining triggers for behaviors, intervening to ensure safety, monitoring hand placement during care, and gently holding the resident’s hands during care as able. On the day of the incident, a nurse aide decided to provide incontinence care around suppertime after the resident had a bowel movement, before meal trays arrived. During the first brief change, the resident remained calm while the aide talked to him. After the brief was applied, the resident had a second bowel movement, and the aide began incontinence care again. At that point, the resident started to hit and pinch the aide, who then stopped care and used her radio to summon a second staff member. She reported that all other staff were occupied providing care in other rooms. While waiting, she was able to calm the resident and, without a second staff member present, resumed incontinence care. The resident, who was facing away from her while she was wiping his rectal area, grabbed the metal bed frame, pulled himself off the bed, and fell, striking his head on a nearby dresser. The aide stated it was normal for him to hold onto the bed frame during care and believed it was a comfort measure. She also stated that the resident was not care planned for a two‑person assist during ADL care and acknowledged that the accident might have been avoided if she had waited for assistance. When the nurse responded to the aide’s call after the fall, the resident was found lying on the floor between the bed and the dresser, bleeding from a forehead laceration. The nurse documented that the aide reported the resident had pulled himself off the bed while she was cleansing him after a large soft bowel movement. The resident’s vital signs were recorded, and he was sent to the emergency department, where he was treated for a soft tissue skin tear to the forehead that required cleansing and steri‑strips. Imaging, including a head CT and pelvic x‑ray, showed no acute injury. Interviews with the nurse, DON, and Administrator confirmed that the resident was known to become combative during ADL care, that the aide had attempted to obtain help but resumed care alone once the resident calmed, and that the resident pulled himself off the bed while holding the bed frame during incontinence care, resulting in the fall and injury.
Inaccurate MAR Documentation for Constipation Medication
Penalty
Summary
The deficiency involves the facility’s failure to accurately document the administration and refusals of Linzess, a medication for chronic constipation, for one resident. A physician’s order dated 04/16/25 directed that Linzess 290 mcg be given orally once daily on Sunday through Friday. Review of the Medication Administration Records (MARs) for November, December, and January showed multiple entries by several nurses and medication aides indicating that the resident received single capsules of Linzess on numerous dates. However, during interviews, Nurse #1, Medication Aide #1, Medication Aide #2, and Nurse #4 each admitted they had documented that the medication was administered on Sundays, Mondays, Wednesdays, and Thursdays when it was not actually given and was instead left or stored in the resident’s room. Nurse #4 further stated that, for as long as she could remember, the resident had actually been taking three capsules of Linzess only on Tuesdays and Fridays, not daily as ordered. The Nurse Practitioner reported that she relied on the MAR documentation to determine whether medication changes were needed and expected accurate documentation at all times. The Consulting Pharmacist stated she would have expected staff to accurately document refusals of the daily Linzess dose and emphasized that the MAR is used to make clinical decisions and that accurate refusal documentation could have supported earlier intervention, such as a medication change. The DON also stated that nursing staff should have accurately documented refusals of Linzess and that the MAR is an important clinical tool that must be accurate at all times.
Misappropriation of Resident's Pain Patch by Staff Member
Penalty
Summary
The facility failed to protect a resident's right to be free from misappropriation of property when a staff member, Nurse #2, took a Duragesic pain patch that was ordered for a resident. The incident involved Resident #29, who was admitted with a diagnosis of chronic back pain and was cognitively intact according to the Minimum Data Set. On the morning of the incident, Nurse #2, who was not scheduled to work, entered the facility and went into Resident #29's room, allegedly to replace a Duragesic patch. However, the patch was not replaced, and Nurse #2 was later found to be hypotensive and exhibiting signs of low oxygenation. The Director of Nursing (DON) was notified of the situation, and an investigation was conducted. It was revealed that Nurse #2 had taken the patch from Resident #29, which was confirmed by Nurse #2 himself. The investigation included interviews with various staff members, including Nurse #3, who had worked with Nurse #2 that morning. Nurse #3 reported that she had given Nurse #2 a new patch to apply to Resident #29, but later discovered that the patch was not on the resident. The Assistant Director of Nursing (ADON) and the Nurse Practitioner (NP) were also involved in assessing the situation and ensuring that Resident #29 received a replacement patch. The incident was reported to the local police department, the North Carolina Board of Nursing, and the North Carolina Department of Health and Human Services. Nurse #2 was terminated from his position, and the facility conducted an in-service for staff on communication, reporting, medication administration, and protecting their licenses. Despite the incident, Resident #29 did not report any pain or recall missing any doses of the pain patch, and there were no adverse reactions noted.
Neglect in Providing Meal to Dependent Resident
Penalty
Summary
The facility neglected to provide a breakfast tray for a dependent resident, identified as Resident #212, who was admitted with diagnoses including hemiplegia following a stroke and aphasia. The resident was assessed as cognitively impaired and dependent on staff for personal hygiene, toileting, oral hygiene, and eating. Her care plan indicated she was at nutritional risk and required staff assistance with feeding at mealtimes. On the morning of the incident, the Director of Nursing (DON) was informed by a Dining Assistant that Resident #212's breakfast tray was still in the kitchen warmer, indicating that the resident had not been fed. Nursing Assistant #1, who was responsible for Resident #212 during the shift, admitted to forgetting to provide the breakfast tray. Interviews with the Dining Assistant and Nurse #1 confirmed that the nursing assistants were responsible for obtaining meal trays for residents who ate in their rooms and required feeding assistance. Despite being aware of the resident's dependency, NA #1 did not retrieve the tray or seek help from other staff members. The DON confirmed that breakfast was typically served between 7:30 AM and 9:00 AM, and NA #1 acknowledged forgetting the task without requesting assistance.
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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