Willow Ridge Of Nc
Inspection history, citations, penalties and survey trends for this long-term care facility in Rutherfordton, North Carolina.
- Location
- 237 Tryon Road, Rutherfordton, North Carolina 28139
- CMS Provider Number
- 345197
- Inspections on file
- 30
- Latest survey
- March 19, 2026
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Willow Ridge Of Nc during CMS and state inspections, most recent first.
Surveyors found that the facility developed standardized care plans for intimate relationships and sexual activity for several severely cognitively impaired residents, documenting that they wished to have intimate relationships and that responsible parties or family had consented. These care plans included goals about meeting sexual choices/preferences and interventions such as staff education on safe sex practices, provision of private areas for consensual intimate activities, and use of door signage for privacy. However, staff interviews revealed that these residents only held hands, hugged, or danced and did not engage in sexual contact, and that the intimate-relations focus areas were added based on corporate instruction rather than individualized assessment. The DON and Administrator acknowledged that care plans should be individualized and accurate, but the written plans did not reflect the residents’ actual behaviors or their severe cognitive impairment.
Staff failed to protect resident privacy when they entered rooms without knocking, announcing themselves, or waiting for permission, despite residents being cognitively able to grant or deny entry. Two residents reported that staff routinely came into their rooms without knocking, causing them to feel angry, disrespected, and deprived of privacy. During observations behind fully closed doors, a nurse and a NA each opened a resident’s door and entered unannounced. In interviews, both staff members acknowledged they knew from residents’ rights training that they were required to knock and wait for permission, but one stated he did not realize he had failed to knock and the other stated he sometimes forgot when in a hurry. The DON and Administrator confirmed their expectation that all staff knock, announce themselves, and wait for permission before entering.
A resident was admitted with documented bipolar disorder, dementia, and other medical conditions, and was prescribed multiple antidepressant and psychotropic medications. A Level I PASRR completed before admission instructed that paperwork be resubmitted for a Level II PASRR if a mental health diagnosis was suspected or if there was a significant change, and the admission MDS listed bipolar disorder as an active diagnosis. Psychiatry notes and the care plan reflected ongoing treatment and monitoring for bipolar disorder, yet the SW Director only submitted Level I PASRR paperwork and did not include supporting psychiatric or medical documentation. No Level II PASRR request was ever submitted, and facility leadership later acknowledged that a Level II PASRR evaluation should have been completed but was not.
A resident with Alzheimer’s disease and identified nutritional risk experienced significant weight loss while on a mechanically altered, therapeutic diet. An RD and physician initially ordered a fortified nutritional shake BID, which was later discontinued after some weight gain. As the resident’s weight continued to decline, the RD repeatedly documented that the resident was receiving the fortified shake and recommended its continuation and later an increase to TID. However, MAR reviews over several months showed no active orders for the supplement, and interviews revealed that staff assumed the RD, DON, or unit coordinators would enter supplement orders based on risk meeting discussions but did not verify that orders were actually in place. This breakdown in communication and order entry resulted in the resident not receiving the prescribed fortified nutritional shake despite ongoing documented weight loss.
A resident with atrial fibrillation and heart failure, cognitively intact and needing assistance with ADLs, had long, jagged toenails and brown discoloration of the right great toenail that were not addressed by staff. Nursing assessments and the EMR contained no documentation of toenail issues, offers of toenail care, podiatry referrals, or refusals, even though a NA and a nurse both noticed the long, discolored nails and did not report, document, or act on these findings. The resident stated he had repeatedly requested toenail trimming, had not refused such care, and believed a podiatry visit had been promised but never arranged. Review of podiatry schedules showed the resident was not listed, and there were no podiatry consults or visit notes, while leadership acknowledged awareness of the toenail problem without corresponding documentation of care or refusals.
A cognitively impaired male resident with a history of sexualized behaviors was found on top of a female resident in her bed, and later entered another room, allegedly getting on top of a cognitively intact resident. Despite being on one-to-one supervision, the male resident was left unattended, leading to these incidents. The facility failed to protect residents from abuse due to inadequate supervision and monitoring.
A resident with a history of traumatic brain injury and behavioral issues was sent to a hospital for a psychiatric evaluation. Despite being cleared for discharge after three days, the resident remained in the hospital for over a month due to the facility's refusal to readmit him. The facility's Administrator and DON had initially planned to transfer the resident to another facility, but when that fell through, they sent him to a hospital in South Carolina. Multiple attempts by the hospital and the resident's guardian to facilitate his return were unsuccessful until the State Agency intervened.
Three residents in the facility were unable to access their light switches due to broken cords, causing inconvenience and reliance on staff assistance. Despite observations and interviews confirming the issue, nursing staff were initially unaware, and maintenance had not addressed the problem. The residents had varying levels of cognitive and physical impairments, exacerbating the impact of the inaccessible switches.
The facility failed to complete the CAAS of the MDS comprehensively for two residents, leading to deficiencies in addressing the underlying causes and contributing factors of triggered care areas. One resident had six out of eight triggered areas inadequately analyzed, while another had all five triggered areas lacking comprehensive analysis. The MDS Coordinator confirmed the omissions, and both the Administrator and DON expected comprehensive completion of the CAAS.
A Consultant Pharmacist failed to identify a drug irregularity for a resident with anxiety disorder, who had an active PRN Ativan order without a stop date. The Medical Director did not include stop dates in his orders and was unaware of the 14-day duration requirement for PRN psychotropic medications. The oversight was noted during a survey, as the Consultant Pharmacist did not report the irregularity despite conducting medication regimen reviews.
A facility failed to ensure a PRN psychotropic medication order for a resident with anxiety disorder was time-limited and included a rationale for extended therapy. The order for Ativan lacked a stop date, and staff interviews revealed a lack of awareness regarding policy adherence. The Medical Director did not include stop dates and was unaware of the 14-day requirement for PRN psychotropic medications.
A resident with severely impaired cognition was found with an unsecured tube of zinc oxide paste in their room. The paste, which should have been stored in the medication cart, was left unattended on the bedside table. Nursing staff did not notice the paste during their rounds, and the Director of Nursing suggested it might have been brought in by the resident's daughter. The facility's protocol for securing medications was not followed.
A resident was transferred to a hospital in South Carolina for psychiatric evaluation without prior notification to their legal guardian. The facility administrator informed the guardian only after the transfer, citing the need for a geriatric psych unit not available locally.
The facility failed to report an allegation of resident-to-resident abuse to the State Agency, law enforcement, and APS within the required timeframe and did not ensure the report included accurate information. A male resident entered a female resident's room, sat on her bed, and left. Initial reports to law enforcement did not include all details, such as the male resident removing his pants and getting on top of the female resident. The facility's investigation concluded no willful intent or evidence of sexual intercourse, and APS decided not to follow up.
A facility failed to thoroughly investigate an alleged resident-to-resident abuse incident involving a cognitively intact resident and a severely cognitively impaired resident. The investigation lacked a statement from the impaired resident and proper assessments for both involved residents. The Administrator retyped staff statements for clarity but did not retain originals, and the Director of Nursing did not perform a comprehensive physical assessment on the alleged victim.
A resident was transferred to a hospital for psychiatric evaluation without written notification to their legal guardian. The facility informed the guardian by phone but failed to provide the required written notice, as confirmed by interviews with the guardian and Administrator.
The facility failed to post daily nurse staffing information in a location accessible to residents. Observations showed the posting was in a locked lobby, requiring staff assistance for resident access. Interviews with the Scheduler, DON, and Administrator confirmed the posting's location and acknowledged its inaccessibility.
Inaccurate Intimate-Relations Care Plans for Cognitively Impaired Residents
Penalty
Summary
The deficiency involves the facility’s failure to develop accurate, individualized comprehensive care plans for several cognitively impaired residents, specifically related to intimate relationships and sexual activity. Record review showed that four residents with diagnoses including Alzheimer’s disease, unspecified dementia, and neurocognitive disorder with Lewy bodies were all assessed as severely cognitively impaired on their quarterly MDS assessments. Some of these residents also exhibited behaviors such as verbal aggression, rejection of care, and wandering. Despite this, each of these residents had an active care plan focus area indicating a desire for an intimate relationship with a consenting resident partner, with documentation that responsible parties or family had given consent for such relationships. The care plans for these residents included goals stating that the residents would have their psychosocial needs and sexual choices/preferences met with dignity and privacy. Interventions listed in the care plans directed nursing staff to provide education in safe sex practices, including sexually transmitted infection prevention and hygiene, to ensure signage on doors to private areas used for intimate activity to maintain privacy and dignity, and to provide private areas for consensual intimate activities upon request. These interventions were written as if the residents were engaging in or planning to engage in sexual activity and were able to consent to such activity, despite their severe cognitive impairment documented on the MDS. Staff interviews further clarified that the actual resident behaviors did not match the written care plans. The Memory Care Unit Coordinator stated that residents on the secured memory care unit held hands, hugged, and danced, but that no residents engaged in sexual contact. The MDS Nurse reported that she completed the intimate relations care plan focus areas based on corporate instruction and understood that the residents only held hands or danced together, not that they engaged in sexual behaviors; she also stated she did not question whether these care plans were appropriate for the residents involved. The DON and Administrator both acknowledged that care plans should be individualized, accurate, appropriate, and up to date, and the DON explained that the care plans were implemented because responsible parties had given consent for residents to hold hands, hug, and dance, while confirming that no sexual activity occurred between residents. This mismatch between documented care plan goals/interventions and the residents’ actual conditions and behaviors led to the cited deficiency.
Failure to Knock and Obtain Permission Before Entering Resident Rooms
Penalty
Summary
The deficiency involves staff failing to protect residents’ personal privacy by not knocking, announcing themselves, and waiting for permission before entering resident rooms. One cognitively intact resident, admitted on an unspecified date, reported that staff routinely entered his room without knocking, or gave only a single knock while already entering, without announcing themselves or waiting for his permission, regardless of whether the door was open or closed. He stated that this made him very angry, that he had repeatedly asked staff to knock before entering, and that he had given up on having any privacy and felt like a prisoner with no rights. While an observation was conducted with this resident in his room behind a fully closed door, a nurse opened the door and entered without knocking or announcing himself. In a subsequent interview, this nurse acknowledged he did not realize he had entered without knocking, and stated he knew from annual residents’ rights education that he was required to knock and wait for permission from cognitively able residents. Another resident, assessed as moderately cognitively intact, also experienced staff entering his room without knocking. During an observation conducted while sitting with this resident in his room behind a fully closed door, a nurse aide opened the door and entered unannounced. The resident reacted by smacking the mattress, asking the aide what he was doing, pounding his fist on his leg, and repeatedly telling the aide to knock on the door. In an interview, this resident reported that staff never knocked before entering, that this made him feel like a child, and that staff had no respect for him, which made him angry. In a later interview, the nurse aide stated he knew he was supposed to knock before entering a resident’s room and had received training on residents’ rights, including the requirement to knock and wait for permission when residents are able to grant it, but admitted that when he was in a hurry, he forgot to knock. The DON and Administrator both stated in interviews that their expectation, consistent with residents’ rights training, was that staff knock, announce themselves, and wait for permission before entering resident rooms.
Failure to Obtain Level II PASRR for Resident With Bipolar Disorder
Penalty
Summary
The deficiency involves the facility’s failure to submit a required Level II Preadmission Screening and Resident Review (PASRR) evaluation for a resident with a serious mental illness diagnosis. The resident was admitted with documented diagnoses including bipolar disorder, dementia, hypertension, heart failure, and diabetes mellitus. A Level I PASRR had been completed prior to admission with instructions to resubmit paperwork for a Level II PASRR if a mental health diagnosis was suspected or if there was a significant change in condition. The admission MDS assessment identified bipolar disorder as an active diagnosis and documented that the resident had not been evaluated by a Level II PASRR, despite being on multiple antidepressant and psychotropic medications. Hospital discharge records listed bipolar disorder as a diagnosis and included prescriptions for bupropion XL, duloxetine, rivastigmine, and trazodone, which were continued after admission. Psychiatry notes from the facility’s Psychiatric NP documented ongoing treatment and monitoring for bipolar disorder and dementia, with continued psychiatric oversight deemed medically necessary due to chronic psychiatric illness and the need for structured monitoring. The resident’s care plan included focus areas for antidepressant use related to bipolar disorder and insomnia, as well as a mood problem related to bipolar disorder, with interventions such as administering medications as ordered, monitoring for side effects and effectiveness, and behavioral health consults as needed. Despite these documented mental health diagnoses, medications, and ongoing psychiatric management, there was no evidence in the medical record that a Level II PASRR request was ever submitted. The Social Work Director, who was responsible for PASRR paperwork, reported that he had submitted paperwork only for a Level I PASRR and did not include psychiatric or medical progress notes or a signed FL2 form. The facility received a letter stating that the existing Level I PASRR could be used until it expired, but no expiration date was provided, and no further action was taken to obtain a Level II PASRR. Both the Social Work Director and the Administrator later acknowledged that, based on the resident’s bipolar disorder diagnosis, a Level II PASRR evaluation should have been completed, but it was not submitted.
Failure to Implement RD-Recommended Nutritional Supplement for Resident With Significant Weight Loss
Penalty
Summary
The deficiency involves the facility’s failure to implement and maintain physician-ordered nutritional supplements in accordance with RD recommendations for a resident with significant weight loss. The resident was admitted with Alzheimer’s disease and had a care plan identifying potential nutritional problems related to a mechanically altered and therapeutic diet, with interventions including RD evaluation and diet changes as needed. The resident’s weight declined from an admission weight of 206 lbs to 185 lbs, with an RD note documenting a 7.8% weight loss in 30 days and recommending fortified foods. A physician subsequently ordered a fortified nutritional shake 120 ml twice daily for weight loss, and the resident’s weight later increased to 186 lbs before the fortified shake was discontinued. Following discontinuation of the fortified shake, the resident’s weight continued to decline, with documented weights of 171 lbs, 173.5 lbs, 168.5 lbs, and 161.5 lbs over subsequent months. RD notes on multiple dates (12/1, 12/8, 1/16, and 2/12) documented ongoing significant weight loss over 30, 90, and 180 days, BMIs in the obese range, and repeatedly indicated that the resident was receiving a fortified nutritional shake 120 ml twice daily, with recommendations to reweigh, monitor, continue the plan of care, and later increase the shake to 120 ml three times daily. However, review of the MARs for December, January, and February showed no active orders for the fortified nutritional shake, either twice or three times daily, despite these RD notes and a progress note from a risk meeting directing continuation and later increase of the supplement. Interviews with nursing staff, the RD, unit coordinator, nurse supervisor, DON, NP, and administrator revealed that floor nurses relied on the MAR to administer supplements and did not see an active order for the fortified shake. Staff reported that supplement orders were generally expected to be entered by the RD, DON, or unit coordinators based on risk meeting discussions and RD recommendations, but no one verified that the orders were actually entered or active. The RD acknowledged that the fortified shake should have been restarted in December and increased in February per her recommendations and that she did not know why the orders were not entered. The DON and unit leadership described a process in which RD recommendations were read aloud and progress notes were written, but they did not confirm that corresponding orders were in place. As a result, the resident did not receive the ordered fortified nutritional shake despite documented significant weight loss and repeated RD recommendations and risk meeting notes indicating that the supplement was or should be in use.
Failure to Provide Toenail and Podiatry Care for a Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate foot care and arrange podiatry services for a cognitively intact resident with atrial fibrillation and heart failure who required moderate assistance with ADLs and was dependent for bathing. On admission and in subsequent weekly nursing assessments from late January through mid-March, there was no documentation of issues with the resident’s toenails, despite observations on March 16 that both feet had long, jagged toenails and the right great toenail had brownish discoloration extending from the base toward the middle of the nail. The resident reported having asked several times for toenail trimming, stated he had never refused toenail care, and said he had been told he would see a podiatrist but believed no appointment had been made. The EMR contained no documentation that toenail or podiatry care was offered or refused, although it did show refusals of showers and UNNA boot care. Staff interviews confirmed awareness of the toenail condition but revealed no follow-through. A NA who frequently cared for the resident stated he had noticed the toenails were very long and needed trimming but did not recall reporting this to a nurse and had not asked the resident about toenail trimming. A nurse reported the resident had been admitted with long, discolored toenails, especially the right great toe, but acknowledged he did not document this, notify the provider, or attempt to trim the nails, and he had not informed social work of the need for podiatry. The podiatry clinic schedules for February and March did not list the resident, and there were no podiatry consult notes or visit documentation in the EMR since admission. The Social Work Director stated he was unaware of any podiatry needs for this resident until a nurse requested adding the resident to the podiatry list on the day of the interview. The DON stated she was aware of the toenail issue and believed the resident refused care frequently, including toenail care, but there was no documentation of such refusals in the EMR.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect residents from abuse, specifically resident-to-resident abuse, involving two residents who were severely cognitively impaired and one resident who was cognitively intact. The first incident involved a male resident with a history of traumatic brain injury and cognitive impairment, who was found on top of a female resident in her bed with his brief pulled down and his penis exposed. The female resident's brief was found sideways but still in place. This incident occurred despite the male resident being placed on one-to-one supervision due to wandering and sexualized behaviors. In a separate incident, the same male resident entered the room of two other residents, one of whom was cognitively intact, and allegedly got on top of one of them. The resident reported that the male resident removed his pants and got on top of her, prompting her to tell him to get off and leave. The male resident was supposed to be under one-to-one supervision at the time, but the assigned staff left him unattended, allowing him to wander into the room. The facility's failure to maintain adequate supervision and prevent these incidents highlights a significant deficiency in protecting residents from abuse. The male resident's care plan included interventions for his sexualized behaviors and wandering, but these measures were not effectively implemented, leading to the incidents. The facility's investigation noted that the male resident's behaviors were not previously documented, and staff were not aware of the potential for such incidents, indicating a lack of proper assessment and monitoring of the resident's behavior.
Facility Fails to Readmit Resident After Hospitalization
Penalty
Summary
The facility failed to allow a resident to return to the first available bed after being sent to the hospital for a medical and psychiatric evaluation. The resident, who had a history of traumatic brain injury, altered mental status, and cognitive communication deficit, was admitted to the hospital for a psychiatric evaluation due to wandering and sexual behaviors. Despite being medically and psychiatrically cleared for discharge after three days, the resident remained in the hospital for over a month because the facility refused to readmit him. The hospital case manager and the resident's legal guardian made multiple attempts to communicate with the facility's Administrator and Director of Nursing (DON) to facilitate the resident's return. The facility had initially planned to transfer the resident to another skilled nursing facility, but that placement fell through. The facility's Administrator and DON decided to send the resident to a hospital in South Carolina for a psychiatric evaluation, bypassing the local hospital, which did not have a psychiatric unit. The facility's refusal to readmit the resident persisted despite the hospital's and guardian's efforts to resolve the situation. Interviews with the facility's staff, including the Administrator, DON, and Medical Director, revealed a lack of coordination and communication regarding the resident's discharge and readmission. The facility's Administrator denied refusing to take the resident back, despite documentation from the hospital indicating otherwise. The facility eventually agreed to readmit the resident after intervention from the State Agency, but the delay resulted in the resident remaining in the hospital for an extended period, causing potential distress and disruption to his care.
Inaccessible Light Switches for Residents
Penalty
Summary
The facility failed to ensure that residents had access to their light switches, which were located behind their beds, for three residents reviewed for accommodation of needs. Resident #76, who had intact cognition but was unable to walk more than 10 feet due to medical conditions, could not reach the light switch cord, which was broken and only 10 inches long. Despite expressing the inconvenience during an interview, the issue remained unresolved during subsequent observations. Nursing staff who frequently cared for Resident #76 were unaware of the broken cord until it was pointed out. Resident #364, with intact cognition and impairment on one side of her lower extremity, also faced similar issues. The light switch cord behind her bed was broken and only 3 inches long, making it inaccessible. She expressed frustration over her inability to reach the switch due to recent knee surgery, requiring staff assistance each time she needed the light. Observations confirmed the issue persisted, and nursing staff admitted they had not noticed the problem until it was highlighted. Resident #54, with moderately impaired cognition, was unable to reach the light switch cord, which was broken and 10 inches long. Despite being able to walk independently in the corridor, she found it inconvenient to reach the switch from her bed. Nursing staff, including a nurse who had noticed the issue and reported it to maintenance, confirmed the cord was still inaccessible. The Maintenance Director acknowledged the need for immediate repairs but could not recall addressing the issue, highlighting a gap in communication and timely response to repair needs.
Incomplete CAAS for Two Residents
Penalty
Summary
The facility failed to complete the Care Area Assessment Summary (CAAS) of the Minimum Data Set (MDS) comprehensively for two residents, leading to deficiencies in addressing the underlying causes and contributing factors of triggered care areas. Resident #48, who was admitted with diagnoses including dementia, anxiety disorder, and depression, had an MDS assessment that triggered eight care areas. However, the facility did not provide comprehensive analysis for six of these areas, including cognitive loss/dementia, activities of daily living functional/rehabilitation potential, falls, dental care, pressure ulcer/injury, and psychotropic drug usage. The CAAS lacked detailed information on the nature of the resident's problems, possible causes, contributing factors, and reasons for care planning. Similarly, Resident #82, admitted with Alzheimer's disease, bipolar disorder, and chronic pain, had an MDS assessment that triggered five care areas. The facility again failed to provide comprehensive analysis for all five areas, which included activities of daily living functional/rehabilitation potential, falls, nutritional status, pressure ulcer/injury, and psychotropic drug use. The MDS Coordinator confirmed the omissions and acknowledged the error, noting that the assessments were submitted by a former coordinator. The Administrator and Director of Nursing both expressed expectations for comprehensive completion of the CAAS, including underlying causes and contributing factors.
Consultant Pharmacist Fails to Identify PRN Psychotropic Drug Irregularity
Penalty
Summary
The Consultant Pharmacist failed to identify drug irregularities related to the use of a PRN psychotropic drug for a resident with an anxiety disorder. The resident was admitted with moderately impaired cognition and had an active physician's order for Ativan without a stop date. The Consultant Pharmacist conducted medication regimen reviews on two occasions but did not identify the lack of a stop date for the PRN Ativan order, attributing the oversight to human error. The Medical Director, who was responsible for the order, admitted to not writing stop dates and was unaware of the 14-day duration requirement for PRN psychotropic medications. The Director of Nursing and the Administrator both expected the Consultant Pharmacist to identify and report drug irregularities in a timely manner. However, the Consultant Pharmacist's failure to do so resulted in a deficiency being noted during the survey. The Medical Director's practice of not including stop dates and relying on medication reviews at refill requests contributed to the oversight, as did the Consultant Pharmacist's failure to notice the irregularity during the medication regimen reviews.
Failure to Time-Limit PRN Psychotropic Medication Orders
Penalty
Summary
The facility failed to ensure that a physician's order for a PRN psychotropic medication for a resident was time-limited and included a rationale for therapy exceeding 14 days. The resident, who was admitted with an anxiety disorder and had moderately impaired cognition, received Ativan as needed for anxiety without a stop date on the order. The order was not reviewed for accuracy, and the rationale for extending the therapy beyond 14 days was not documented in the resident's medical records. Interviews with staff revealed a lack of awareness and adherence to the facility's policy regarding PRN psychotropic medications. Nurses working the third shift, who were expected to review orders for accuracy, were unaware of this responsibility. The Director of Nursing and the Administrator both expected orders to be written per facility policy, but the oversight was not caught during the review process. The Medical Director admitted to not writing stop dates on his orders and was unaware of the 14-day duration requirement for PRN psychotropic medications.
Unsecured Medication Found in Resident's Room
Penalty
Summary
The facility failed to secure an opened tube of zinc oxide paste for a resident with severely impaired cognition. During an observation, the tube was found unattended on the bedside table in the resident's room. The resident was unable to provide information about how long the paste had been there. Interviews with the nursing staff revealed that the paste should have been stored in the medication cart, but neither the nurse nor the nurse aide noticed it during their rounds. The Director of Nursing suggested that the resident's daughter might have brought the paste to the facility, but reiterated that it should have been kept in the medication cart. The Administrator also expressed the expectation that nursing staff should ensure no medications are left unattended in residents' rooms. This incident highlights a lapse in the facility's medication storage protocol, as the zinc oxide paste was not secured as required.
Failure to Notify Legal Guardian Before Resident Transfer
Penalty
Summary
The facility failed to communicate with and obtain authorization from a resident's legal guardian before transferring the resident across state lines to a hospital in South Carolina. The resident, who was under the guardianship of the local Department of Social Services, was transferred for an in-patient psychiatric evaluation and treatment due to wandering and sexualized behavior. The facility's medical director ordered the transfer, but there was no written or verbal notification to the legal guardian prior to the transfer. The legal guardian was informed by the facility administrator only after the resident had already been transferred. The guardian expressed a desire to have been notified beforehand, especially since there was a local hospital nearby that could have provided treatment. The administrator acknowledged the lack of prior notification and explained that the decision to transfer the resident to a hospital in South Carolina was due to the availability of a geriatric psych unit, which the local hospital did not have.
Failure to Timely Report Resident-to-Resident Abuse
Penalty
Summary
The facility failed to report an allegation of resident-to-resident abuse to the State Agency, law enforcement, and Adult Protective Services (APS) within the required timeframe and did not ensure the report included accurate information. The incident involved a male resident entering the room of a female resident, sitting on her bed, and then leaving. The facility became aware of the incident on 12/19/24 at 1:30 AM, but the initial report to the State Agency was not submitted until 12/26/24. The initial report indicated that law enforcement had been contacted on 12/19/24 at 3:00 AM, but it did not specify if APS had been contacted. Interviews with the Director of Nursing (DON) and the Administrator revealed that they were informed of the incident around midnight on 12/18/24 and arrived at the facility between 12:30 AM and 1:00 AM on 12/19/24 to begin their investigation. The initial information provided to law enforcement was that the male resident had entered the room, sat on the bed, and left without any inappropriate contact. However, a later police report indicated that the male resident had removed his pants and got on top of the female resident, which was not initially reported by the Administrator. The facility's 5-day investigation report, completed on 12/26/24, concluded that there was no willful intent by the male resident and no evidence of sexual intercourse. The report also noted that the female resident's responsible person alleged she had been raped, but the facility did not substantiate this claim. The report was sent to APS, who decided not to follow up and forwarded it to the state for further review. The Administrator admitted to not being aware of the need to send a new report or contact APS prior to the 5-day investigation, as they had no evidence of abuse.
Incomplete Investigation of Alleged Resident-to-Resident Abuse
Penalty
Summary
The facility failed to conduct a thorough investigation of an alleged resident-to-resident abuse incident involving three residents. The incident involved a cognitively intact resident who reported seeing another resident, who was severely cognitively impaired, attempting to climb onto her roommate's bed. The facility's policy required a comprehensive investigation, including interviews with all involved parties and assessments of the residents, but these steps were not fully completed. The investigation was incomplete as it did not include a statement from the cognitively impaired resident involved in the incident, nor were assessments documented for either the alleged victim or the alleged perpetrator. The Director of Nursing (DON) conducted a skin assessment on the alleged victim but did not perform a more thorough physical assessment. The Administrator retyped staff statements for clarity but did not retain the original handwritten statements, and the cognitively impaired resident was not assessed or interviewed in a documented manner. The Administrator and DON were involved in the investigation but did not follow the facility's policy requirements for a thorough investigation. The Administrator acknowledged not typing up an interview statement for the cognitively impaired resident and not being aware of the need for a documented assessment. The lack of comprehensive documentation and adherence to the investigation policy led to the deficiency in handling the alleged abuse incident.
Failure to Provide Written Notification of Resident Transfer
Penalty
Summary
The facility failed to provide written notification to the legal guardian of a resident regarding the resident's transfer to a hospital in South Carolina. The resident, who had a legal guardian appointed through the local Department of Social Services, was transferred for an in-patient psychiatric evaluation and treatment due to safety concerns related to wandering and sexualized behavior. The transfer was ordered by the Medical Director, but the facility did not issue a written notification to the guardian, as required. The legal guardian was informed of the transfer via a telephone call from the Administrator, but no written notification was provided. This oversight was confirmed during a telephone interview with the legal guardian, who stated that she did not receive any written communication prior to the transfer. The Administrator acknowledged the lack of written notification during an interview, despite having communicated the transfer verbally.
Inaccessible Nurse Staffing Information
Penalty
Summary
The facility failed to post daily nurse staffing information in a location that was readily accessible to residents on four out of five days during the survey. Observations on multiple days revealed that the daily nurse staffing sheet was placed on a wall in the front lobby, which was only accessible through a door with keypad access. Residents needed to request a staff member to enter the code to view the posting, making it not readily visible or accessible to them. Interviews with facility staff, including the Scheduler, Director of Nursing (DON), and Administrator, confirmed the location of the posting and acknowledged that it was not easily accessible to residents. The Scheduler, who was responsible for posting the daily staffing information, stated that the posting had been in the lobby for a long time. The DON and Administrator both recognized that the current location did not meet the requirement for being readily accessible to residents.
Latest citations in North Carolina
A resident with hemiplegia after a cerebral infarction and chronic atrial fibrillation was receiving rivaroxaban 20 mg daily as an anticoagulant, as documented in active medication orders, the MDS, and the MAR over several months. However, the comprehensive care plan, from admission through a later update, did not include any problem, goal, or intervention related to anticoagulant use. The MDS Coordinator stated she reviews and updates care plans after MDS completion and acknowledged she had overlooked adding anticoagulant use to the care plan, while the Administrator reported an expectation that all high-risk medications, including anticoagulants, be reflected in resident care plans.
A resident with a chronic heel wound with drainage, classified as high risk under the facility’s Enhanced Barrier Precautions (EBP) policy, received wound care from a Wound Nurse and a NA who wore masks and gloves but did not don gowns during multiple high-contact wound care activities on both lower extremities. The facility’s EBP policy requires both gloves and gowns for high-contact care, including wound care, for residents with chronic wounds. At the time of care, there was no EBP sign on the door and no PPE caddie or supplies outside the room. In subsequent interviews, the Wound Nurse and NA reported they did not wear gowns because there was no sign on the door and the nurse was not wearing one, while the IP and DON stated they would have expected gown use and confirmed that wound care is considered a high-contact activity under the policy.
Over more than a year, residents repeatedly reported during Resident Council meetings that call lights were not answered timely, staff sometimes turned off call lights without meeting needs, ice and water were not passed consistently on all shifts, water pitchers were not washed as expected, and care was not always provided during meal times. Residents also described staff using poor attitudes, including cursing and aggressive tones, and noted that coffee on hall carts was often empty or cold at breakfast. Despite these concerns being raised month after month, residents stated they felt the facility only responded by saying staff were being educated, while the same problems continued. The Social Worker and DON acknowledged that these issues had been discussed numerous times without true resolution, and residents expressed a desire for their needs to be met and for clear feedback from administration about efforts to address their ongoing concerns.
A resident was admitted with documented PTSD and COPD, and hospital records showed PTSD as a chronic condition monitored during hospitalization. Although the care plan and MDS admission assessment identified PTSD as an active psychiatric/mood disorder and the resident received an antidepressant, the PASRR Determination Notification reflected only a Level I PASRR, and the FL2 form from the hospital did not list PTSD. The SW, who was responsible for PASRR submissions, relied on quarterly audits of admission paperwork and the MDS to identify cases needing Level II PASRR, resulting in no timely Level II request being submitted for this resident’s PTSD diagnosis.
Surveyors found multiple opened nutritional supplement containers in unit nourishment refrigerators that were either undated or stored beyond the manufacturer’s specified use-by timeframe. A one-quart shake in one unit refrigerator lacked an opening date despite a label requiring use within four days of opening, while two dated one-quart shakes and an opened, undated diabetic shake in another unit refrigerator were not managed according to their labeled time limits. The DM reported that nursing staff, not dietary, were responsible for dating and discarding resident nutritional shakes, while dietary staff only checked and restocked kitchen-provided items. A nurse and the Administrator both confirmed that the person opening the shake was responsible for dating it and ensuring it was used or discarded within the manufacturer’s guidelines.
A resident with ESRD, peripheral vascular disease, and an AV fistula returned from dialysis with a gauze dressing applied by the dialysis nurse, which remained in place into the following day. A physician order and care plan required nursing staff to remove the AV fistula dressing on the night of dialysis and assess the site for complications and signs of infection. The assigned nurse acknowledged she knew she was required to remove the dressing and assess the site but forgot because she was busy with another resident. The physician emphasized the importance of post-dialysis AV fistula assessment due to the resident’s vascular disease and prior complications, and the DON stated she expected staff to follow the order and routinely assess the fistula site.
A resident admitted with bipolar disorder, generalized anxiety disorder, vascular dementia with severe behavioral disturbance, and active BPSD was maintained on multiple psychotropic medications, including an antipsychotic with a documented contraindication to gradual dose reduction, but only had a Level I PASRR on file. At admission, the SW verified that a PASRR existed in NC MUST but did not confirm that the resident’s mental health diagnoses were captured, and no Level II PASRR request was submitted. The SW reported she relied on prior guidance that a Level I PASRR was sufficient unless there was a change in condition, and the Administrator confirmed the SW was responsible for Level II PASRR submissions, resulting in the failure to obtain a required Level II determination.
A resident with dementia, stroke, dysphagia, and severe cognitive impairment, who was edentulous and dependent for ADLs, was care planned and listed on the NA Kardex to receive assisted oral care at least twice daily. Over nearly a month, NA documentation showed denture care was provided only three times, and surveyors observed the resident’s upper and lower dentures with brown stains and debris buildup. One NA, assigned on several day shifts, believed the resident did not have dentures and only offered mouthwash and a basin, while another NA, aware the resident wore dentures, usually did not perform denture care because the resident was already in bed and did not want to remove them. The DON later confirmed the dentures had visible debris and staining and that the care plan required regular oral care and proper denture cleaning.
The facility failed to ensure residents received their mail in a timely manner, particularly mail delivered on Saturdays. During a council meeting, several residents reported that Saturday mail was not brought to them until Monday. The new Activity Director did not work weekends and was unfamiliar with the weekend mail process. The weekday receptionist stated that the weekend receptionist had no key to the outdoor mailbox, so mail was not retrieved on Saturdays unless the Business Office Manager was present. The Business Office Manager confirmed that when she was absent on weekends, no one else could access or deliver residents’ mail, and that after the prior Activity Director left, there was no designated staff to deliver weekend mail, resulting in periods when residents did not receive their mail on the day it arrived.
The facility failed to maintain and implement its antibiotic stewardship and infection surveillance program, as required by its own policy. For most months reviewed, there were no infection control records, including antibiotic order listings, documentation confirming infections, surveillance logs, or trend analyses, and the only available data for one month was an unstructured list of residents who received antibiotics without formal tracking of infection rates or antibiotic use. The DON, who was also expected to serve as the Infection Preventionist, reported being unable to locate infection control reports or surveillance data for an extended period, and the Administrator confirmed that, during a time of multiple interim DONs, infection control tracking and analysis of infection and antibiotic use trends had not been completed.
Failure to Care Plan for High-Risk Anticoagulant Therapy
Penalty
Summary
The facility failed to develop an individualized comprehensive care plan addressing anticoagulant medication use for a resident who had been prescribed rivaroxaban 20 mg daily with the evening meal for a history of cerebral infarction. The resident was admitted with hemiplegia following a cerebral infarction and chronic atrial fibrillation, and the active medication orders showed continuous administration of rivaroxaban from its start date through the survey review period. The quarterly MDS assessment documented that the resident was receiving an anticoagulant, and the Medication Administration Record confirmed daily administration of rivaroxaban over several months. Despite this ongoing anticoagulant therapy and the resident’s relevant diagnoses, the comprehensive care plan dated at admission and updated later did not include any focus area, goals, or interventions related to anticoagulant use. During an interview, the MDS Coordinator acknowledged that the care plan did not address the anticoagulant medication and stated that she must have overlooked it when updating the care plan after completing the MDS assessment. In a separate interview, the Administrator stated that her expectation was that all resident care plans reflect high-risk medications, including anticoagulants.
Failure to Follow Enhanced Barrier Precautions During Wound Care
Penalty
Summary
The deficiency involves the facility’s failure to implement its Infection Control policies and procedures for Enhanced Barrier Precautions (EBP) during wound care for a resident. The facility’s EBP policy, last revised on 04/15/26, requires staff to don both gloves and a gown for high-contact care activities with high-risk residents, including those with chronic wounds. High-contact activities listed in the policy include wound care, and the policy specifies that residents with chronic wounds should remain on EBP for the duration of their stay or until the wound resolves. Resident #12 was admitted with a chronic heel wound with drainage, placing the resident in the high-risk category under the EBP policy. During an observation of wound care on 05/12/26 at 12:33 PM, the Wound Nurse and Nurse Aide (NA) #1 entered the resident’s room wearing masks and gloves but no gowns. There was no EBP sign on the door and no PPE caddie or supplies outside the room. The resident was seated in a wheelchair beside the bed with the door open. The Wound Nurse performed multiple wound care steps on the resident’s right leg, right heel, left third toe, and left heel, repeatedly donning and doffing gloves and performing hand hygiene, while NA #1 assisted by holding the resident’s legs. At no point during these high-contact wound care activities did either staff member wear a gown. In interviews following the observation, the Wound Nurse stated he did not wear a gown because there was no sign on the door indicating the resident was on EBP and later acknowledged learning that a gown should have been worn. NA #1 similarly reported that she did not wear a gown because there was no sign on the door and the Wound Nurse was not wearing one, and she later learned that both should have worn gowns. The Infection Preventionist (IP) stated that the resident should have had an EBP sign on the door and a PPE caddie available, and explained that the sign and supplies were likely left on the resident’s previous room after a move. The IP and the Director of Nursing both stated they would have expected the Wound Nurse and NA #1 to wear gowns while providing wound care, and the DON identified wound care as a high-contact activity requiring gown use under the facility’s EBP policy.
Ongoing Failure to Resolve Resident Council Concerns About Call Lights and Basic Services
Penalty
Summary
The deficiency involves the facility’s failure over a 13‑month period to effectively resolve and communicate resolution of repeated concerns raised in Resident Council meetings, particularly regarding call light response times, staff turning off call lights without meeting needs, inconsistent ice and water pass, and care during meal times. Resident Council minutes from multiple months document that residents, especially those on the 200 hall, repeatedly reported that call lights were not answered in a timely manner and that staff sometimes turned off call lights and left without providing the requested care. Residents also reported that when they turned their call lights back on, staff questioned why they had done so, despite their needs not having been met. These concerns were documented as new issues in successive meetings, indicating that the same problems persisted over time. The Resident Council minutes further show that residents repeatedly complained that ice was not being passed consistently on second and third shifts and on all halls, and that water pitchers were not being washed weekly as expected. At various meetings, residents stated that ice was not being passed daily on all shifts, that ice was not being passed routinely, and that ice was not being passed on every shift. Additional concerns were raised about staff attitudes, including cursing and using an aggressive tone of voice, and about care not being provided during meal times. Residents also reported that coffee on the hall cart was often empty or cold at breakfast. These issues were brought up under both Old Business and New Business in multiple meetings, demonstrating that residents perceived them as ongoing, unresolved problems. During a Resident Council group interview, several residents who lived on the 200 hall and regularly attended the meetings stated they felt the facility did not truly address their concerns because the typical response they heard was that staff were being educated, yet the same problems continued. Multiple residents agreed that call lights not being answered timely was a continual problem and expressed that they wanted resolution and their needs to be met, as well as feedback from administration about efforts made to address their concerns. The Social Worker confirmed that call light response time, passing ice on all shifts, and providing care during meal times had been discussed numerous times and acknowledged there was still no resolution to these issues. The DON acknowledged that grievances from Resident Council regarding clinical issues were assigned to her and that the 200 hall was considered challenging, with residents there being more alert, oriented, and vocal about their needs, but the ongoing nature of the same complaints showed that the facility did not effectively resolve or communicate resolution of the residents’ repeated concerns. The Administrator, who had recently started in the role, stated that they were hoping to achieve resolution of the call light response concerns and that call lights should be answered as quickly as possible, with staff not turning off call lights and failing to return to meet residents’ needs. Despite these stated expectations, the documented Resident Council minutes and resident interviews demonstrate that residents continued to experience and report the same issues over many months. Overall, the deficiency centers on the facility’s inaction and ineffective response to recurring Resident Council complaints, resulting in residents feeling that their concerns about call light response, ice and water service, staff behavior, and care during meals were not being resolved or adequately addressed.
Failure to Request Level II PASRR for Resident With PTSD Diagnosis
Penalty
Summary
The facility failed to submit a request for a Level II PASRR evaluation for a resident admitted with a serious mental health disorder. The resident’s hospital course and treatment note documented chronic post-traumatic stress disorder (PTSD), which was monitored during that hospitalization. A PASRR Determination Notification letter showed the resident only had a Level I PASRR with no expiration date. The North Carolina Medicaid FL2 Level of Care Screening Tool completed by the hospital social worker and sent to the facility did not list PTSD as a diagnosis, even though the resident was admitted with diagnoses including COPD and PTSD. The resident’s care plan, initiated shortly after admission, identified a risk for impairments or complications due to a history of PTSD and included interventions such as approaching the resident calmly, avoiding triggers, building a trusting relationship, obtaining psychiatric referrals as needed, and involving the resident in care decisions. The admission MDS assessment indicated the resident was not considered by the state Level II PASRR process to have a serious mental illness or intellectual disability, but it did list PTSD as an active psychiatric/mood disorder diagnosis and documented that the resident received an antidepressant during the assessment period. The facility social worker, who was responsible for submitting Level II PASRR requests, acknowledged that the resident had a PTSD diagnosis that was not included on the FL2 and stated she conducted PASRR audits on a quarterly basis by reviewing admission paperwork and the MDS to identify diagnoses requiring Level II submission. She reported she was in the process of completing these audits and preparing to submit requests, including one for this resident. The administrator stated that the social worker should have reviewed the admission diagnoses and MDS triggers and requested a Level II PASRR evaluation for the resident’s PTSD at the time of admission or within a month of admission or new diagnosis, rather than waiting for quarterly audits.
Failure to Date and Discard Opened Nutritional Supplements per Manufacturer Instructions
Penalty
Summary
The deficiency involves the facility’s failure to properly date and discard opened containers of nutritional supplements stored in nourishment room refrigerators on the North and South Units. During observations of these refrigerators with the Dietary Manager, surveyors found a one-quart nutritional shake in the North Unit refrigerator with no date indicating when it was opened, despite the manufacturer’s label stating it must be used within four days after opening if refrigerated. In the South Unit refrigerator, surveyors observed two one-quart nutritional shakes dated 4/24 and 4/28, both beyond the manufacturer’s four-day use-by period, as well as an opened and undated 8-ounce diabetic nutritional shake whose label required use within 48 hours of opening. In interviews, the Dietary Manager stated that dietary staff did not stock the nutritional shakes in the nourishment refrigerators and that nurses were responsible for the nutritional shakes given to residents, including dating them when opened and discarding them when past the use-by date. The Dietary Manager also explained that dietary staff checked the nourishment refrigerators twice daily only for items provided by the kitchen, including restocking and checking expiration dates on those snacks and drinks. A nurse confirmed that a physician’s order was required for a resident to receive a nutritional shake and that nurses were responsible for dating the shakes when opened and ensuring they were used and discarded according to the manufacturer’s instructions. The Administrator stated that the person who opened a nutritional shake was responsible for writing the date opened on the container and noted that historically dietary staff checked dates on food and drinks stored in the nourishment refrigerators.
Failure to Remove Dialysis AV Fistula Dressing and Perform Ordered Assessment
Penalty
Summary
The facility failed to follow a physician’s order to remove a dressing and visually assess a resident’s arteriovenous (AV) fistula after dialysis. The resident, who had diagnoses including AV fistula, end stage renal disease, dialysis, and peripheral vascular disease, was cognitively intact and received dialysis. A physician order dated 2/2/2026 directed staff to remove the dressing to the AV fistula on the night of dialysis every Monday, Wednesday, and Friday to avoid skin breakdown and damage to the AV fistula. The resident’s care plan, updated on 2/27/2026, included interventions to check and change the AV fistula dressing as ordered and to observe the site for signs and symptoms of infection. On observation, the resident was noted to have a gauze dressing with tape on the left upper arm AV fistula the day after dialysis, and the resident reported that the dressing had been applied by the dialysis nurse after treatment. The nurse assigned to the resident on the 3:00 PM to 11:00 PM shift acknowledged that she was supposed to remove the dressing and assess the AV fistula site when the resident returned from dialysis but stated she forgot because she was busy with another resident. The physician stated that it was important for nursing staff to remove the dressing and assess the AV fistula after dialysis due to the resident’s significant vascular disease and history of complications with hypotension and falls after dialysis, and described the AV fistula as the resident’s lifeline. The DON stated that nursing staff usually removed the dressing and assessed the AV fistula site after dialysis and that she expected staff to follow physician orders and assess for signs and symptoms of infection.
Failure to Request Level II PASRR Evaluation for Resident With Serious Mental Illness
Penalty
Summary
The deficiency involves the facility’s failure to submit a request for a Level II PASRR evaluation for a resident admitted with serious mental health disorders. A PASRR Determination Notification letter showed the resident had only a Level I PASRR with no expiration date. The resident was admitted with diagnoses including bipolar disorder, generalized anxiety disorder, and vascular dementia with severe behavioral disturbance. A psychiatric progress note documented a long history of bipolar disorder and recent behavioral and psychological symptoms of dementia, with active diagnoses of bipolar disorder, bipolar depression, and generalized anxiety disorder. The resident was receiving multiple psychotropic medications, including duloxetine, clonazepam, quetiapine (in both morning and bedtime doses), and trazodone. The admission MDS assessment indicated the resident was not considered by the state Level II PASRR process to have a serious mental illness or intellectual disability, despite active psychiatric/mood disorder diagnoses of anxiety disorder and bipolar disorder and ongoing antipsychotic use with a physician-documented contraindication to gradual dose reduction. An NC MUST inquiry confirmed that only a Level I PASRR, effective more than a year prior, was on file and that no PASRR requests for a Level II determination had been submitted prior to the survey date. The Social Worker reported that she checked NC MUST for a current PASRR at admission but did not verify whether mental health diagnoses were included in the initial screening, and she relied on prior guidance from a PASRR evaluator that a Level I PASRR was sufficient unless there was a change in condition. The Administrator stated the Social Worker was responsible for submitting Level II PASRR requests and acknowledged that, based on this prior guidance, a Level II request for this resident was not completed.
Failure to Provide Ordered Denture and Oral Care for Dependent Resident
Penalty
Summary
The facility failed to provide ordered assistance with denture and oral care for a dependent resident with severe cognitive impairment, dementia, stroke, dysphagia, and edentulism. The resident’s admission MDS documented severely impaired cognition, a need for setup or clean-up assistance with oral hygiene, and no refusal of care or behaviors. The care plan and NA Kardex both directed staff to provide or assist with oral care at least twice daily using a soft toothbrush or foam swabs, and identified the resident as at risk for oral and dental health problems and dependent in ADL self-care. However, NA documentation showed denture care was recorded as provided only three times over nearly a month-long period. During observation, the resident reported wearing upper and lower dentures and displayed dentures with brown stains and debris buildup around the teeth and gums, stating he could brush his dentures if he had a toothbrush and toothpaste. One NA, assigned on multiple day shifts, stated she provided only mouthwash and a basin because the resident had difficulty brushing, believed the resident did not have dentures, and confirmed she had not provided denture care. Another NA on night shift acknowledged knowing the resident wore dentures, having seen them on the bed or nightstand, but stated she usually did not perform denture care because the resident was already in bed and did not want to remove them, and described denture care only as soaking them overnight. When the DON later observed the dentures, he confirmed visible debris and brown staining, and acknowledged that the care plan and Kardex required oral care at least twice daily and that dentures should be brushed and soaked overnight.
Failure to Ensure Timely Weekend Mail Delivery to Residents
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents’ right to receive mail, including mail delivered on Saturdays. During a Resident Council group interview, several residents reported that when mail was delivered to the facility on Saturdays, it was not distributed to them until Monday by the Activity Director. Multiple residents agreed with this account, and no residents present disagreed. The new Activity Director, who had transitioned from working as a Certified Occupational Therapist Assistant on 04/24/26, stated she did not work weekends and was unsure how mail delivery to residents was handled on weekends. Staff interviews further showed that the weekend receptionist did not have a key to the outdoor mailbox and therefore could not retrieve Saturday mail. The weekday Receptionist reported that she collected the mail from the outdoor mailbox on Monday mornings and gave it to the Business Office Manager, after which the Activity Director delivered it to residents. The Business Office Manager confirmed that if she was not at work on weekends, no one else had access to the outdoor mailbox. She stated she worked most Saturdays, checked and sorted the mail, and then gave residents’ mail to activity staff or delivered it herself, but noted that after the previous Activity Director left 6–7 weeks earlier, there was no one designated to deliver mail to residents on weekends when she was not present. The Administrator acknowledged that there were approximately three weeks when weekend mail was not delivered to residents due to turnover in the activity department and the absence of an Activity Director.
Failure to Maintain Facility-Wide Antibiotic Stewardship and Infection Surveillance
Penalty
Summary
The facility failed to implement a facility-wide system to monitor antibiotic use as required by its Antibiotic Stewardship Program policy. The policy, last revised in December 2016, required that all clinical infections treated with antibiotics undergo review by the Infection Preventionist or designee, including review of antibiotic utilization, antibiotic orders, clinical documentation confirming infections, infection surveillance logs, microbiology testing, and trends in infection and antibiotic use data. Surveyors found that for eight of nine months reviewed—July, August, September, October, November, and December 2025, and February and March 2026—the facility was unable to provide any infection control data, including listings of antibiotic orders, clinical documentation confirming infections, surveillance logs, or trending of infections. For January 2026, the facility had only a list of residents who exhibited symptoms and were treated with antibiotics, but did not use a structured tool to track infection rates, antibiotic use, or to monitor, conduct surveillance, or identify trends related to infections or possible infections. During interviews, the DON, who assumed the position on April 13, 2026 and was also expected to function as the Infection Preventionist, reported being unable to locate Infection Control reports, surveillance records, or infection tracking data for July 2025 through April 2026, except for the January list of residents who received antibiotics. The Administrator confirmed that multiple interim DONs had served since July 2025 and acknowledged that tracking of infection control data, including infection trends and antibiotic use, had not been completed, despite the facility’s stated intent for a comprehensive Infection Control Program that included surveillance, tracking, and trend analysis.
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