White Oak Manor - Charlotte
Inspection history, citations, penalties and survey trends for this long-term care facility in Charlotte, North Carolina.
- Location
- 4009 Craig Avenue, Charlotte, North Carolina 28211
- CMS Provider Number
- 345238
- Inspections on file
- 24
- Latest survey
- April 13, 2026
- Citations (last 12 mo.)
- 10 (2 serious)
Citation history
Health deficiencies cited at White Oak Manor - Charlotte during CMS and state inspections, most recent first.
A cognitively impaired, exit-seeking resident with dementia, insomnia, gait abnormalities, orthostatic hypotension, and high fall risk repeatedly wandered at night and was known by staff to push on an emergency exit door. On two consecutive nights, the resident left the building unsupervised through a west hall emergency exit that had been manually left unlocked and with its door alarm turned off, so no alarm sounded when it was used. After the first elopement, the nurse and NA did not verify that the door’s lock and alarm were re-engaged, and no new monitoring was implemented, allowing the resident to exit again a few hours later. Maintenance later confirmed the door hardware and alarm were functioning properly and could only be disabled manually, meaning staff actions and inactions in securing and monitoring the door directly enabled both elopements.
Surveyors identified multiple failures in food labeling, storage, and sanitation, including dirty water spigots above the cooking range, a scoop stored with its handle in direct contact with rice, and unsealed croissants without open or use-by dates in a walk-in cooler. In three nourishment rooms, open food items such as a half-eaten creme pie with used forks, a reusable container of dressing, a pudding cup, a fast-food sandwich, and a milkshake were found without required open and/or use-by dates. The Dietary Manager reported that all nourishment room food must be labeled with both an open date and a 7-day use-by date and noted that new staff and nursing staff were not consistently labeling items as required.
A resident with severe cognitive impairment who used a wheelchair for mobility was observed being quickly pulled backward down a hallway while reclined in a geriatric chair, instead of being pushed forward in a dignified manner. The NA reported he pulled the chair backward because he felt it was harder to push forward, and he was unaware of any equipment problems. A SW later tested the same geriatric chair and found it functioned properly. Facility leadership, including the Staff Development Director, DON, and Administrator, stated that staff are educated on residents’ rights, dignity, and wheelchair use, and confirmed the expectation that residents be pushed forward in wheelchairs and geriatric chairs at a normal, dignified pace.
A resident with severe cognitive impairment and ADL deficits, including dependence on staff for bathing and grooming, was observed multiple times with long, stringy, visibly greasy and dirty hair despite being scheduled for twice-weekly showers. Nursing staff reported providing bed baths instead of full showers and only wetting the resident’s hair, while hospice staff provided intermittent bed baths with no-rinse shampoo and were unsure of the facility’s regular shower routine. The resident had not been to the beauty shop for hair care in over two months due to being mistakenly left off the beauty shop list. Facility leadership expected that the resident’s hair would be properly washed on scheduled shower days but could not identify when the hair was last washed, resulting in a failure to provide appropriate hair washing services.
Staff failed to follow Enhanced Barrier Precautions (EBP) by not wearing gowns during high-contact care activities for two residents on EBP. In one case, a nurse provided catheter care to a resident with an EBP sign and available PPE but wore only gloves, later stating she believed gowns were needed only when changing the catheter. In another case, two NAs used a mechanical lift to transfer a resident with a gastrostomy tube, again with EBP signage and PPE present, but wore only gloves; one NA stated he did not view transferring as high-contact care, and the other reported she did not always use gowns for transfers. These actions conflicted with the facility’s EBP policy and posted instructions requiring both gown and gloves for high-contact activities such as catheter care and transfers.
A resident with diabetes, sepsis, and end stage renal disease did not receive ordered twice daily blood sugar checks due to a transcription error when a nurse failed to correctly enter a verbal physician order into the EMR. As a result, no blood sugar monitoring was performed during the resident's admission, despite a care plan identifying the need for such monitoring.
A resident with venous ulcers and impaired cognition, along with a roommate, experienced persistent flies and gnats in their room, leading a family member to purchase a UV insect trap after repeated complaints to staff. Staff and housekeeping confirmed the presence of pests, often linked to open food and trash, while the pest control company had no record of such issues. Surveyors also observed gnats in a conference room, and the administrator was previously unaware of the problem.
A resident with a history of DVT and pulmonary embolus had their anticoagulant, Eliquis, discontinued for a medical procedure and it was not restarted afterward due to oversight by the NP and failure of multiple staff, including the Medical Director, to detect the omission. Over several months, the resident developed symptoms such as leg swelling and shortness of breath, which culminated in hospitalization for bilateral pulmonary emboli and required a thrombectomy. The deficiency was caused by the lack of a restart order for Eliquis and repeated failures to recognize the medication was not being administered.
Medical providers did not accurately review or update the medication list in progress notes for a resident with atrial fibrillation and benign prostatic hyperplasia. Eliquis was discontinued prior to a procedure, but subsequent NP and MD notes continued to list it as active, despite it not being restarted. The medication lists were carried over from previous notes and did not reflect actual medication changes, with staff relying on the MAR for accuracy. The administrator and DON were aware of inaccuracies in the progress note medication lists but did not know how the lists were generated.
A resident with a history of atrial fibrillation and pulmonary embolus experienced a prolonged interruption in anticoagulant therapy after Eliquis was discontinued for a surgical procedure and not resumed for several months. The Consultant Pharmacist did not identify or address this lapse during monthly drug regimen reviews, and facility leadership confirmed the omission should have been detected.
The facility failed to ensure dishware and equipment were clean during a meal service. Observations revealed divided plates with dried egg particles and bowls with dried food particles. The Registered Dietitian and Regional Dietary Manager confirmed these findings. Despite a three-step cleaning process, Dietary Aides did not adequately check the dishes before use, as noted by the Dietary Manager and Administrator.
Two residents in an LTC facility received incorrect oxygen flow rates, contrary to physician orders. One resident with chronic respiratory failure was observed with an oxygen concentrator set higher than prescribed, while another resident with congestive heart failure had a lower than prescribed rate. Nursing staff failed to verify and adjust the oxygen settings, leading to deficiencies in respiratory care.
The facility failed to discard expired medications and allowed a resident to keep and self-administer a prescription topical cream without staff knowledge. An expired bottle of omega-3 vitamins was found in the medication room, and a resident had a lidded container of medicated cream at their bedside, which was not prescribed in-house. The resident, who had intermittent confusion, was not assessed to self-administer medications, and the facility was unaware of the cream's presence.
A Treatment Nurse failed to follow the facility's Hand Hygiene policy during wound care for a resident, neglecting to sanitize hands before donning clean gloves multiple times. This was observed during the treatment of wounds on the resident's legs. Interviews with staff revealed awareness of the error, and the nurse acknowledged forgetting to sanitize due to frequent glove changes.
A resident, dependent on staff for transfers and requiring a sit-to-stand lift, was assisted by a nurse aide in a stand and pivot transfer without the lift, leading to both ending up seated on the bed. The resident had expressed feeling stronger and requested the transfer without the lift, but the nurse aide's actions were deemed unsafe by facility staff.
Unsecured Emergency Exit Allows Repeated Elopement of High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to keep an emergency exit door secured and alarmed, which allowed a cognitively impaired, exit-seeking resident at high fall risk to leave the building unsupervised on two consecutive nights. The resident had dementia with psychotic disturbance, severe cognitive impairment, a history of wandering and exit-seeking, orthostatic hypotension, gait abnormalities, and muscle weakness. Care plans and assessments identified wandering, exit seeking, fall risk, and insomnia, and interventions included a wander guard bracelet, frequent safety checks, environmental monitoring, and redirection from exits. Despite this, the resident routinely wandered at night, roamed the halls, entered other residents’ rooms, and was known by staff to push on the emergency exit door in attempts to leave. On the first night, in the early morning hours while it was still dark, the nurse noticed the resident was no longer in the hallway or in his room. The assigned NA, positioned near the west hall emergency exit, reported hearing a door slam but assumed it was a nearby resident’s room door because the emergency door alarm had not sounded. When the nurse checked the emergency exit, he found it unlocked and non-alarming, exited through it, and after walking several minutes from the back of the building to the front, located the resident standing at the main entrance. The resident’s wander bracelet triggered the main entrance door alarm when they re-entered, confirming the bracelet was in place. The nurse believed the emergency door locked and re-armed automatically and did not verify the lock or alarm status of the door after the incident or before the end of his shift, and no additional monitoring or new interventions were implemented at that time. On the second night, the same nurse observed the resident in bed at approximately 1:30 AM, but by about 2:00 AM the resident was again missing from his room. The nurse immediately went to the same west hall emergency exit and saw the resident outside through the door’s glass, walking away from the building. The door was again unlocked and did not alarm when opened. The nurse brought the resident back inside through that door and assessed him with no injuries noted. Staff interviews and maintenance inspection confirmed that the emergency exit door’s magnetic lock was controlled by a wall switch and the red alarm box on the door could only be turned on or off with a key; the system did not malfunction and could not be defeated by holding the push bar. This meant the door’s lock and alarm had been manually disabled by staff on at least one prior shift, and staff on subsequent shifts, including nurses and NAs who were aware of the resident’s exit-seeking behavior and the first elopement, did not verify that the door was secured and alarmed, allowing the resident to exit a second time without staff knowledge.
Removal Plan
- Identify recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance
- Ensure Resident #89 has a wander bracelet in place
- Pursue or redirect Resident #89 back into the facility if he exits
- Assess Resident #89 for acute distress or injury after an elopement event
- Administer scheduled bedtime medications for insomnia (melatonin 3 mg and trazodone 50 mg) as ordered
- Initiate an order for checks of Resident #89’s whereabouts
- Document completion of checks on the Medication Administration Record
Improper Food Labeling, Storage, and Sanitation in Kitchen and Nourishment Rooms
Penalty
Summary
The facility failed to properly label, date, and store food items and to maintain cleanliness in food preparation and nourishment areas. During an initial kitchen tour with the Dietary Manager, surveyors observed visible dirt and grime buildup on three water spigots above the cooking range and found a plastic scoop left in a rice bin with the handle and bottom in direct contact with the rice. In walk-in cooler #2, a cardboard flat of croissants had been cut open, with seven croissants already used, and the remaining croissants were not resealed or labeled with an open or use-by date. The Dietary Manager acknowledged that the open croissants had been missed by kitchen staff and that the rice scoop should have been stored in its designated holder on the bin. In three nourishment rooms, surveyors found multiple food items that were open but not properly labeled with open and/or use-by dates. In one nourishment room refrigerator, there was a half-eaten creme pie with three used plastic forks left in the pan and a small reusable container of ranch dressing, both open and unlabeled. In another nourishment room refrigerator, a vanilla pudding cup and a wrapped fast-food sandwich were open and labeled only with open dates, but no use-by dates. In a third nourishment room refrigerator, a fast-food milkshake was open with no open or use-by date. The Dietary Manager stated that all nourishment room food items were required to be labeled with both an open date and a use-by date set seven days after opening, and reported that some new staff were not labeling items correctly and that nursing staff often left items in nourishment refrigerators without appropriate labeling.
Resident Dignity Compromised During Transport in Geriatric Chair
Penalty
Summary
The deficiency involves a failure to maintain a resident’s dignity and right to a dignified existence and self-determination when a nurse aide transported the resident in a manner inconsistent with facility expectations. The resident, who had clear speech but severe cognitive impairment and required a wheelchair for mobility, was observed during a continuous observation being quickly pulled backward approximately 30 feet down the South Hall from the day room to her room while reclined in a geriatric chair. A reasonable person would have expected to be treated with dignity and to be wheeled forward in the chair. During interviews, the nurse aide stated he chose to pull the resident backward because he felt it was harder to push the reclined geriatric chair forward and reported no awareness of problems with the chair. The social worker later pushed the same geriatric chair forward and backward in the hallway and noted no functional concerns, stating the chair worked fine and needed no repairs. The Staff Development Director reported that staff receive education on residents’ rights, dignity, and wheelchair use, including speed and footrest use, and acknowledged the resident should not have been pulled backward in the geriatric chair. The DON and Administrator both stated they expected staff to push residents in wheelchairs and geriatric chairs forward, at a normal pace, and in a dignified manner.
Failure to Provide Adequate Hair Washing for Dependent Resident
Penalty
Summary
The facility failed to provide adequate hair washing services for a dependent resident with ADL deficits. The resident was admitted with senile degeneration of the brain, COPD, and heart failure, and had a care plan identifying ADL deficits due to generalized weakness, with interventions including setup for hair and oral hygiene daily and assistance with bathing and dressing. An annual MDS showed the resident was severely cognitively impaired and required extensive staff assistance for ADLs, with no behaviors or rejection of care documented. The shower schedule indicated the resident was to receive showers twice weekly on specific mornings. However, multiple observations over several days showed the resident in bed with long, stringy, visibly greasy and dirty hair that was stuck flat against her head, including on a scheduled shower day. Record review showed documentation that the resident received a shower on one of the observed days, but the NA assigned that day reported she actually provided a bed bath rather than a full shower and typically only wet the resident’s hair, noting it was becoming tangled, especially in the back. The NA stated a hospice bathing team visited a couple of times a week and used a no-rinse shampoo, but she was unsure of their specific care for this resident. The hospice nurse confirmed providing bed baths with no-rinse shampoo a couple of times a week and was unsure of the facility’s regular shower routine for the resident. The beauty shop operator and unit secretary both indicated it had been longer than two months since the resident’s last beauty shop visit, and the unit secretary acknowledged the resident’s name had been left off the beauty shop list by mistake. The DON stated NAs were expected to bathe the resident twice weekly and was unaware of when the resident’s hair was last washed, while the administrator stated his expectation that the resident’s hair would be properly washed on scheduled shower days.
Failure to Use Required Gowns Under Enhanced Barrier Precautions During High-Contact Care
Penalty
Summary
The deficiency involves the facility’s failure to follow its own Enhanced Barrier Precautions (EBP) policy requiring the use of gowns and gloves during high-contact resident care activities for residents on EBP. The written policy, revised on 7/26/2022, defined EBP as an infection control intervention to reduce transmission of multidrug-resistant organisms (MDRO) by using gowns and gloves during high-contact activities such as dressing, bathing, transferring, providing hygiene, changing linens or briefs, assisting with toileting, and device care or use, including urinary catheters and feeding tubes. Facility signage for EBP instructed staff to don a gown and gloves for high-contact resident care activities, and personal protective equipment (PPE), including gowns, was made available in holders at resident room doors. During an observation of catheter care for Resident #132, who was on EBP and had an EBP sign and PPE bin with gowns posted outside the room, Nurse #5 entered the room without wearing a gown. She washed her hands, donned gloves, removed the resident’s brief, and provided catheter care, then discarded supplies and gloves and washed her hands. In a subsequent interview, Nurse #5 acknowledged awareness that the resident was on EBP but stated she believed a gown was only required when changing the catheter, not when providing catheter care, and indicated she must have misunderstood the EBP instructions despite having received infection control training. In a separate observation, Resident #161’s room also had an EBP sign and PPE holder on the door, and the resident had a gastrostomy tube with tube feeding formula hanging at the bedside. When the resident returned from an outside appointment in a wheelchair, two nurse aides entered the room with a mechanical lift to transfer the resident to bed. Both aides wore gloves but did not wear gowns while completing the mechanical lift transfer. One aide stated he knew the resident was on EBP due to the gastrostomy tube but believed a gown was only required when performing “some type of care” and did not consider transferring to be a high-contact activity, even when shown the sign indicating gowns and gloves were required for transfers. The other aide, who usually worked on a different unit, stated she followed EBP signage but sometimes used a gown for transfers and not all the time, and both aides had previously received EBP and PPE training. The Infection Preventionist, DON, and Administrator each stated that staff should have worn gowns in these situations according to the posted EBP signage and facility expectations.
Failure to Transcribe Physician Order for Blood Sugar Monitoring
Penalty
Summary
A deficiency occurred when a verbal physician's order for twice daily blood sugar checks was not correctly transcribed into the electronic medical record for a resident admitted with diagnoses including sepsis, diabetes mellitus, failure to thrive, and end stage renal disease requiring hemodialysis. The order, given by the Medical Director, was entered by a nurse who failed to select the appropriate option in the electronic system, resulting in the order not appearing on either the Medication Administration Record or the Treatment Administration Record. As a result, no blood sugar checks were performed during the resident's stay. The resident's care plan identified diabetes mellitus and the risk for related complications, with interventions to monitor for signs and symptoms of hyperglycemia and hypoglycemia. Despite this, a review of the electronic medical record showed no documentation of blood sugar monitoring from admission to discharge. Interviews with facility staff, including the DON and the nurse who entered the order, confirmed the transcription error and lack of blood sugar checks. The Medical Director confirmed the order was given due to the resident's history of low blood sugar episodes prior to admission.
Failure to Effectively Manage Flies and Gnats in Resident Room and Common Area
Penalty
Summary
The facility failed to effectively manage pests, specifically flies and gnats, in at least one resident room and in the conference room. A resident with peripheral vascular disease and venous ulcers, who had moderately impaired cognition, reported seeing flies and gnats in his previous room. His family member confirmed that flies and gnats were present on multiple occasions, leading her to purchase and install a UV insect trap in the room after receiving permission from a previous administrator. The family member stated that the issue was reported to numerous staff members, and another resident who shared the room also reported persistent insect problems, resorting to purchasing spray to address the issue himself. Observations during the survey did not find insects in the room at that time, but staff interviews confirmed the presence of flies and gnats in the past, often attributed to open food and trash left in the room. Nursing and housekeeping staff acknowledged the presence of flies and gnats in the affected room, noting that the residents kept open snacks and trash, which attracted the pests. The wound nurse and nurse aides confirmed that the family had brought in a UV insect trap and that extra cleaning and trash removal were attempted. The Director of Housekeeping reported that the room was cleaned multiple times daily due to ongoing issues with food debris and trash, and she had observed gnats and flies herself. The Maintenance Director stated that he did not keep a log of pest complaints and would address issues as they were reported, but he did not recall being notified about flies or gnats in this particular room. The facility had a contract with a pest control company for monthly treatments, but the pest control representative had no record of complaints about flies or gnats, only treating for rodents and cockroaches during recent visits. Additionally, surveyors observed small winged gnats in the facility conference room during their visit. The new administrator was unaware of any fly or gnat problem prior to the survey but acknowledged that such pests should not be present in resident rooms. The lack of effective pest management and communication regarding pest issues led to ongoing problems with flies and gnats in at least one resident room and a common area, as confirmed by multiple staff, residents, and family members.
Failure to Resume Anticoagulant After Procedure Leads to Adverse Outcome
Penalty
Summary
A facility failed to resume an anticoagulant medication, Eliquis, for a resident with a history of deep vein thrombosis (DVT) and pulmonary embolus after it was temporarily discontinued for a scheduled medical procedure. The resident had been admitted with multiple diagnoses, including atrial fibrillation, type 2 diabetes, urinary retention, and a history of blood clots. Eliquis was discontinued on the instruction of the Nurse Practitioner (NP) prior to a suprapubic catheter placement, and no new order was entered to restart the medication after the procedure. The NP later stated that the electronic health record system required discontinuation rather than holding of medications, and she forgot to re-enter the order to restart Eliquis. The Medical Director and other staff also failed to identify that the medication had not been restarted, despite reviewing the resident's medication records multiple times and documenting that the resident was on Eliquis when he was not. Over the following months, the resident began to exhibit symptoms such as bilateral lower extremity edema, shortness of breath, and required supplemental oxygen. Despite these symptoms and multiple clinical assessments, the omission of Eliquis was not identified until a venous doppler was ordered due to leg swelling, which revealed a non-occluding DVT. Only then did the NP realize that the resident was not on anticoagulation and restarted Eliquis. Shortly after, the resident's condition worsened, leading to increased anxiety, hypoxia, and further clinical decline. The resident was eventually transferred to the hospital, where he was diagnosed with bilateral pulmonary emboli, including a complete occlusion in the right lower lobe, and required a heparin drip and thrombectomy. Throughout this period, documentation and interviews revealed that both the NP and Medical Director repeatedly referenced the resident as being on Eliquis in their notes, despite the medication not being administered. The failure to restart the anticoagulant after the procedure, combined with the lack of detection by multiple clinical staff and the limitations of the electronic health record system, directly led to the resident's adverse clinical outcomes, including hospitalization and invasive intervention for blood clots.
Removal Plan
- Audit of current residents on anticoagulant therapy by running current orders for anticoagulants and reviewing the orders for accuracy to determine whether any changes or adjustments with the anticoagulant were made, and verifying the appropriate administering or discontinuing of the medication as ordered.
- The DON ensures residents have their anticoagulant ordered and administered as required, and verifies that the medication is available in the medication cart.
- Audit of current residents on anticoagulant therapy and residents that had discontinued anticoagulant orders by the DON and the Assistant Director of Nursing (ADON).
- Audit by reviewing the Healthcare Practitioner's progress notes and provider's consultations to identify any other medication that have been discontinued specifically focused on anticoagulant medications and have not been restarted.
- Audit by the DON, ADON and the Pharmacy Consultant.
- If any further concerns are identified from the audit, the Healthcare Practitioner will be notified, and the resident will be evaluated.
- Ensure residents' medications will be administered, discontinued and restarted appropriately.
- Licensed Nurses are re-educated on the importance of ensuring a resident's medication, such as an anticoagulant, that is temporarily discontinued due to a procedure, treatment or hospitalization, has been restarted.
- Licensed Nurse must verify that the medication that the resident was taking prior to being discontinued has been reentered, verified and activated, if still deemed medically necessary.
Failure to Accurately Review and Update Resident Medication List in Progress Notes
Penalty
Summary
Medical providers failed to accurately review and update the total plan of care and medication list for a resident with atrial fibrillation and benign prostatic hyperplasia. The resident was admitted to the facility and had Eliquis, a blood thinner, discontinued prior to a suprapubic catheter placement as ordered by the nurse practitioner. Despite this discontinuation, subsequent nurse practitioner and physician progress notes repeatedly listed Eliquis as an active medication, with each note including a statement that the medication list had been reviewed and that the Medication Administration Record (MAR) should be referenced for an up-to-date list. Multiple progress notes over several weeks continued to include Eliquis on the medication list, even though the medication had not been restarted after the procedure. Addendum clinical clarifications were later electronically signed by the physician, stating that the resident was not taking Eliquis on the dates of the progress notes. Interviews with the nurse practitioner and physician revealed that the medication lists in the progress notes were often carried over from previous notes and may not have accurately reflected current medication orders or changes. Both providers indicated reliance on the MAR for the most accurate medication information. The administrator and DON acknowledged awareness that the medication lists in the progress notes were not always accurate, but were not familiar with the specific process by which the medication list was generated for the notes. The failure to restart Eliquis after the procedure and the continued listing of the medication as active in progress notes were not identified or corrected in a timely manner, resulting in inaccurate documentation of the resident's medication regimen.
Pharmacist Failed to Identify Lapse in Anticoagulant Therapy
Penalty
Summary
The facility's Consultant Pharmacist failed to identify and address a significant lapse in anticoagulant therapy for a resident with a history of atrial fibrillation, type 2 diabetes, and pulmonary embolus. Eliquis, an anticoagulant, was discontinued for a surgical procedure and not resumed for approximately three months. During this period, the Consultant Pharmacist conducted monthly drug regimen reviews but did not recommend restarting the medication or document any follow-up regarding its discontinuation, despite reviewing the resident's medical chart, provider notes, and laboratory results. Interviews with the Consultant Pharmacist, Medical Director, Nurse Practitioner, and Director of Nursing confirmed that the omission of Eliquis from the resident's medication regimen was not identified or addressed in the pharmacy reviews. The Medical Director and facility leadership acknowledged that the monthly pharmacy reviews should have detected the prolonged discontinuation and brought it to the attention of the medical team.
Unclean Dishware and Equipment During Meal Service
Penalty
Summary
The facility failed to ensure that dishware, including divided plates and bowls, were clean for use during a meal service observation. During the lunch meal tray line observation, seven divided plates were found with dried egg particles, and the plate warmer also contained dried egg particles. Additionally, two plastic bowls had dried food particles inside and around them. These observations were confirmed by the Registered Dietitian and the Regional Dietary Manager, who noted that most of the divided plates had crumbs or dried egg particles. Interviews with the Dietary Manager and the Regional Dietary Manager revealed that the facility had a three-step process to ensure dishes were clean before use. This process included checks when dishes were removed from the dishwasher, when they were placed on drying racks or in storage, and when they were moved to the tray line for use. However, the Dietary Aides did not pay close attention to the dishes before placing them on the tray line for meal service. The Administrator expressed that she expected the dishes and equipment to be clean and free of debris and food particles before meal service.
Failure to Administer Oxygen at Prescribed Rates
Penalty
Summary
The facility failed to ensure that oxygen was delivered at the prescribed rate for two residents, leading to deficiencies in respiratory care. Resident #41, who was admitted with chronic respiratory failure and hypoxia, had a physician's order for oxygen at 3 liters per minute via nasal cannula. However, observations over several days revealed that the oxygen concentrator was set at 4 liters per minute. Interviews with nursing staff indicated a lack of adherence to the physician's order, as the nursing assistant did not adjust oxygen settings, and the nurse on duty did not verify the flow rate against the physician's order. The Director of Nursing acknowledged the discrepancy and stated that the nursing staff should have ensured the correct flow rate. Resident #101, diagnosed with congestive heart failure and respiratory failure, had a physician's order for oxygen at 3 liters per minute. Observations showed that the oxygen concentrator was set at 1.5 liters per minute, which was below the prescribed rate. The resident, who had severely impaired cognition, was unable to adjust the oxygen settings independently. Interviews with the assigned nurse revealed that the nurse did not check the oxygen flow rate during the observed days. The Director of Nursing confirmed that the resident could not change the settings and expected the nursing staff to provide oxygen at the prescribed rate. Both residents were observed to have incorrect oxygen flow rates over multiple days, indicating a failure by the facility to follow physician orders for oxygen administration. The Director of Nursing and the Administrator both expressed expectations that staff should adhere to physician orders for oxygen settings. The Physician Assistant reiterated the necessity of following prescribed oxygen flow rates for residents receiving supplemental oxygen.
Medication Management Deficiencies in LTC Facility
Penalty
Summary
The facility failed to properly manage medications in the South Hall Medication Room and for a resident. During an observation, an expired bottle of Red [NAME] Oil, an omega-3 vitamin, was found in the medication storage room. The Director of Nursing (DON) confirmed the expiration date and acknowledged that expired medications should not be present in the storage room or medication carts. The DON stated that nursing staff are responsible for weekly checks to ensure expired medications are discarded, indicating a lapse in this protocol. Additionally, a resident was found to have a lidded container of prescription topical medicated cream for fungal infections on their bedside table. The resident, who was cognitively intact but had intermittent confusion, had been applying the cream independently without staff knowledge. The cream was not prescribed in-house, and the facility was unaware of its presence until it was observed by Unit Manager #1. The medicated cream had an expiration date of January 2024, and the Medical Director confirmed it was not appropriate for the resident to self-administer. The facility's policy requires a physician's order for medications to be kept at a resident's bedside, which was not obtained in this case.
Failure to Follow Hand Hygiene Policy During Wound Care
Penalty
Summary
The facility failed to adhere to its Hand Hygiene policy during wound care for a resident, as observed with the Treatment Nurse. The nurse did not perform hand hygiene before donning clean gloves multiple times while treating wounds on the resident's legs. Specifically, after removing gloves, the nurse did not sanitize her hands before putting on a new pair of gloves, which is a requirement according to the facility's infection control policy. This lapse in protocol was noted during the treatment of wounds on both the right and left legs of the resident. Interviews with the Treatment Nurse, Infection Preventionist, Director of Nursing, and Administrator revealed awareness of the errors made during the wound care procedure. The Treatment Nurse acknowledged forgetting to sanitize her hands due to the frequent glove changes required during the procedure. The Infection Preventionist and Director of Nursing both expressed that the expectation was for the nurse to sanitize her hands after each glove removal and before donning new gloves. The Administrator confirmed that the nurse was expected to follow the Hand Hygiene policy, and it was noted that the nurse had performed another dressing change without errors subsequently.
Unsafe Transfer of Resident Without Required Equipment
Penalty
Summary
The facility failed to provide a safe transfer for a resident who was dependent on staff for transfers. The resident, who was cognitively intact and had diagnoses including chronic obstructive pulmonary disease and type 2 diabetes, required two-person assistance using a sit-to-stand lift for all transfers. On the evening of the incident, a nurse aide assisted the resident in a stand and pivot transfer without using the required lift, as the resident expressed feeling stronger and requested to transfer without the lift. During the transfer, the resident's legs became weak, and both the resident and the nurse aide ended up seated on the bed without injury. Interviews with the nurse aide, the nurse, the Director of Nursing, and the Administrator confirmed that the transfer method used was unsafe and not in accordance with the resident's care plan. The nurse aide acknowledged that she should have used the sit-to-stand lift despite the resident's request. The Director of Nursing and the Administrator both stated that the nurse aide's actions were not safe and that the sit-to-stand lift should have been used to ensure the resident's safety during the transfer.
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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