Citations in North Carolina
Comprehensive analysis of citations, statistics, and compliance trends for long-term care facilities in North Carolina.
Statistics for North Carolina (Last 12 Months)
Financial Impact (Last 12 Months)
Latest Citations in North Carolina
A resident with severe cognitive impairment was transported in a geriatric wheelchair by an OT who pulled the chair from behind, preventing the resident from seeing where he was going. This action did not respect the resident's dignity, as confirmed by staff interviews and facility training expectations.
A resident with severe cognitive impairment had a family member designated as their Resident Representative (RR), but there was no documentation of care plan meetings or attempts to contact the RR since admission. The RR reported not being invited to participate in care planning and expressed a desire to be included. The Administrator, responsible for sending care plan invitations after the Social Worker left, could not provide evidence that the RR had been contacted.
A resident with moderate cognitive impairment and chronic pain was found to be self-administering arthritis creams, antacid tablets, and cough drops kept at her bedside without a clinical assessment or physician orders. Facility staff, including nursing and administration, were unaware of the resident's possession and use of these medications, and no care plan or documentation addressed self-administration.
A nurse failed to provide privacy for a resident with severe cognitive impairment and an indwelling urinary catheter by leaving the door open and not pulling the privacy curtain during a catheter assessment, resulting in the resident being exposed and visible from the hallway while staff passed by.
A resident with Diabetes Mellitus II received daily insulin as ordered, but the MDS assessment did not accurately reflect the use of hypoglycemic medication during the required lookback period. Staff confirmed the omission was due to human oversight.
A resident with a diagnosis of PTSD did not have a person-centered care plan addressing this condition, despite a trauma-informed assessment and staff awareness of potential triggers. Nursing staff confirmed that no care plan was developed for PTSD because the resident had not exhibited related problems since admission, resulting in a deficiency.
Two residents prescribed psychotropic medications did not have comprehensive care plans developed within the required timeframe after their assessments. Both had diagnoses such as dementia, anxiety, and depression, and their assessments triggered the need for care planning related to psychotropic medication use. Staff interviews revealed that care plans were not created due to human error and unclear responsibility among staff for updating care plans.
A treatment cart containing wound care medications was left unlocked and unattended in a hallway, accessible to staff, visitors, and a resident. The cart contained topical medications that could be dangerous if accessed by residents. Additionally, Astelin nasal spray was found stored horizontally in two medication carts, contrary to manufacturer instructions requiring upright storage. Nursing staff were unaware of the proper storage requirements, and the DON confirmed expectations for compliance with manufacturer guidelines.
Two staff members failed to follow the facility's Enhanced Barrier Precautions policy by not wearing gowns while providing high-contact care to a resident with an indwelling urinary catheter. Both the nurse aide and the nurse performed catheter care and assessment using only gloves, despite the policy requiring both gowns and gloves for such procedures. Both staff later acknowledged the omission and recognized that gowns were required for this type of care.
Surveyors found that PTAC units in several rooms were not properly aligned or sealed, resulting in visible gaps to the outside and crumbled insulation. In one room, water leakage from a misaligned unit led to wet, soiled linens beneath it. Maintenance staff had recently reinstalled the units after electrical work but failed to secure them correctly, and facility leadership was unaware of the issue until the survey.
Resident Transported in Wheelchair Without Regard for Dignity
Penalty
Summary
A deficiency occurred when a resident, who was severely cognitively impaired, was transported in a geriatric wheelchair by an occupational therapist (OT) in a manner that did not honor the resident's right to dignity. The OT pulled the wheelchair from behind, positioning the resident so that he was unable to see where he was being taken. This action was observed by surveyors and was confirmed during interviews with the OT, who stated she was unaware that this method of transport was a dignity issue and explained she pulled the chair because it was difficult to push. The resident had an active order for occupational therapy evaluation and treatment. The incident was witnessed during a routine observation, and the OT involved was an agency staff member who had received facility training on treating residents with dignity and respect. The Rehabilitation Manager and the DON both acknowledged that staff should have known this method of transport was inappropriate and a concern for resident dignity.
Failure to Include Resident Representative in Care Planning
Penalty
Summary
The facility failed to include the Resident Representative (RR) of a severely cognitively impaired resident in the care planning process. The resident, who was admitted with severe cognitive impairment, had a family member designated as her RR. Review of the medical record showed that the care plan was last revised on 8/18/25, but there was no documentation of care plan meetings, attempts to contact, or conversations with the RR since admission. During a telephone interview, the RR stated he did not recall being invited to any care plan meetings and expressed a desire to be included. The Administrator confirmed that, following the departure of the Social Worker in June 2025, she was responsible for sending care plan meeting invitations but could not provide documentation that the RR had been invited for this resident.
Failure to Assess Resident for Self-Administration of Medications
Penalty
Summary
The facility failed to assess a resident's ability to self-administer medications, resulting in the resident keeping several medications at her bedside without clinical evaluation or physician orders. The resident, who was moderately cognitively impaired and had diagnoses including non-Alzheimer's dementia and chronic pain syndrome, stored and self-administered arthritis cream with 25% capsaicin, arthritis pain relief gel with 2% menthol, chewable antacid tablets, and cough drops. There was no documentation in the medical record of an assessment for self-administration, no physician orders for these medications, and no care plan addressing self-administration. Multiple staff members, including a nurse, unit manager, nurse aide, DON, and the administrator, were unaware that the resident kept and used these medications at her bedside. The nurse reported applying arthritis cream from the medication cart, but was unaware of the resident's personal supply. The DON and administrator confirmed that no assessment for self-administration had been conducted and were unsure how the facility would have known about the medications at the bedside. The lack of assessment and oversight led to the deficiency.
Failure to Provide Privacy During Catheter Assessment
Penalty
Summary
Nurse #2 failed to provide personal privacy for a resident with severe cognitive impairment and an indwelling urinary catheter during a catheter assessment. The nurse entered the resident's room, applied gloves, and proceeded to pull up the resident's gown and pull down his brief to assess the catheter insertion site without closing the door or pulling the privacy curtain. As a result, the resident's bare stomach and penis were visible from the hallway, and staff were observed passing by the open door during the assessment. Prior to this, a nurse aide had performed catheter care for the same resident, closing the door but not pulling the privacy curtain. The resident was in the bed closest to the door, with a roommate present whose privacy curtain was closed. After noticing bloody urine in the catheter tubing, the nurse aide informed Nurse #2, who then entered the room and conducted the assessment without ensuring privacy, leading to the resident's exposure.
Failure to Accurately Code MDS for Hypoglycemic Medication Use
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) assessment for one resident in the area of hypoglycemic medication use. The resident was admitted with a diagnosis of Diabetes Mellitus II and had active physician orders for both long-acting and sliding scale insulin, which were administered daily as documented in the Medication Administration Record. Despite this, the resident's admission MDS assessment did not reflect the use of hypoglycemic medications, including insulin, during the required 7-day lookback period. Staff interviews confirmed that the omission was due to human oversight and that the MDS should have been coded to indicate the resident's receipt of hypoglycemic medication. The deficiency was identified through record review and staff interviews, which established that the resident received insulin as ordered but the MDS assessment failed to accurately capture this information.
Failure to Develop Person-Centered Care Plan for PTSD Diagnosis
Penalty
Summary
The facility failed to develop and implement a person-centered care plan for a resident diagnosed with Post Traumatic Stress Disorder (PTSD), despite the resident having a documented history of PTSD, delusional disorders, mood disorder, and major depressive disorder. A trauma-informed assessment was completed, and the resident was found to be cognitively intact with no behaviors noted during the assessment period. However, review of the care plan revealed there was no plan of care addressing the resident's PTSD diagnosis. Staff interviews confirmed that while the resident had some behaviors such as refusal of care and paranoid behavior, these were care planned separately and not specifically linked to PTSD. Nursing staff, including the MDS Nurse and the Director of Nursing, acknowledged that a person-centered care plan should have been developed for the resident's PTSD, including identification of triggers such as loud noises. The MDS Nurse stated that a care plan was not created because the resident had not exhibited any PTSD-related problems since admission. Despite this, the expectation was that staff should be aware of appropriate interventions should a PTSD episode occur. The lack of a specific care plan for PTSD constituted the deficiency identified during the survey.
Failure to Timely Develop Comprehensive Care Plans for Psychotropic Medication Use
Penalty
Summary
The facility failed to develop a comprehensive care plan within 7 days of completing the comprehensive assessment for two residents who were prescribed psychotropic medications. For one resident with non-Alzheimer's dementia, anxiety, and major depressive disorder, the admission MDS assessment indicated the use of antianxiety and antidepressant medications, and the Care Area Assessment (CAA) was triggered for psychotropic medication use. However, the comprehensive care plan created did not address psychotropic medication use. Staff interviews revealed that the care plan was not created due to human error, and there was confusion among staff regarding responsibility for care plan updates. Similarly, another resident with anxiety, depression, and Alzheimer's dementia was prescribed antianxiety medication, and the CAA was triggered for psychotropic medication use. The care plan for this resident also failed to address psychotropic medication use. Staff interviews indicated that the lack of a clearly identified person responsible for updating care plans after new medication orders contributed to the deficiency. Both the DON and Administrator acknowledged that psychotropic medication use should have been included in the care plans for these residents.
Unsecured Treatment Cart and Improper Medication Storage
Penalty
Summary
Surveyors observed that a treatment cart containing medications used for wound care was left unattended and unlocked in a hallway for 25 minutes. During this time, no staff were present with the cart, and several staff members, visitors, and a resident in a wheelchair passed by the unlocked cart. Upon inspection, the cart was found to contain several topical medications, including antiseptic solution, medical grade honey, hydrocortisone cream, corticosteroid cream, and a cream for skin conditions. The Wound Care Nurse acknowledged forgetting to lock the cart and confirmed that these medications could be dangerous if accessed by a cognitively impaired resident. Both the DON and the Administrator confirmed that the cart should have been locked at all times when not in use, as the medications could pose a danger if ingested. Additionally, surveyors found that Astelin nasal spray, which must be stored upright according to manufacturer instructions, was stored horizontally in two separate medication carts. Nurses responsible for these carts admitted they had not read the manufacturer's instructions and were unaware of the proper storage requirements. The DON stated that nursing staff are expected to check carts and follow all manufacturer guidelines for medication storage, including storing the nasal spray upright if indicated.
Failure to Follow Enhanced Barrier Precautions During Catheter Care
Penalty
Summary
The facility failed to adhere to its infection control policy regarding Enhanced Barrier Precautions (EBP) during high-contact care for a resident with an indwelling urinary catheter. During an observation, a nurse aide entered the resident's room, washed her hands, and applied gloves but did not don a gown, despite gowns being available and required by the facility's EBP policy for catheter care. The nurse aide proceeded to provide catheter care, noted the presence of bloody urine, and completed the task without ever applying a gown. Upon interview, the nurse aide acknowledged forgetting to put on the gown and recognized, after reviewing the posted signage, that a gown was required for this type of care. A similar observation occurred with a nurse who assessed the same resident's indwelling urinary catheter. The nurse entered the room, washed her hands, and applied gloves but did not wear a gown while lifting the resident's gown and lowering the brief to assess the catheter insertion site. After completing the assessment, the nurse disposed of her gloves and washed her hands. In an interview, the nurse admitted to forgetting to apply a gown and confirmed that it was required for catheter care. Both the Staff Development Coordinator and the Director of Nursing confirmed that the staff should have worn gowns during these high-contact care activities, as outlined in the facility's EBP policy.
Failure to Properly Seal and Install PTAC Units in Resident Rooms
Penalty
Summary
Surveyors observed that the facility failed to properly install and seal packaged terminal air conditioners (PTACs) in four out of eight resident rooms reviewed across three of four halls. In multiple rooms, the PTAC units were not aligned with the wall, resulting in gaps ranging from one to two inches at the top of the units. These gaps allowed daylight from the exterior to be visible from inside the rooms, and the insulation present was found to be crumbled or in poor condition. In one room, wet, soiled towels and sheets with brown stains were found underneath the PTAC unit, which was leaning inward and not sealed to the wall. During a facility tour with the Maintenance Director, Regional Maintenance Director, and the Administrator, it was confirmed that the PTAC units remained improperly installed and the gaps persisted. The maintenance staff indicated that the PTAC units had been removed and reinstalled recently to replace electrical cords, but only the middle screws were secured during reinstallation, leaving the units misaligned. The facility leadership was not previously aware of these issues until the surveyors' observations.
Some of the Latest Corrective Actions taken by Facilities in North Carolina
- Implemented in-person education for all nurses and medication aides on manufacturer and facility instructions for cleaning and disinfecting shared glucometers (J - F0880 - NC)
- Established orientation in-service for all newly hired and agency nursing staff covering proper cleaning and disinfection of shared glucometers (J - F0880 - NC)
- Required hands-on return demonstrations of glucometer cleaning/disinfection with remediation until competency was shown (J - F0880 - NC)
- Administered quizzes to verify staff knowledge of glucometer disinfection procedures, with immediate re-education for failing scores (J - F0880 - NC)
Failure to Follow Infection Control Procedures for Glucometer Disinfection, Hand Hygiene, and Linen Handling
Penalty
Summary
Nurse #1 failed to follow the manufacturer's instructions and facility policy for cleaning and disinfecting a shared blood glucose meter (glucometer) after checking a resident's blood glucose level. Instead of using an EPA-registered germicidal wipe as required, Nurse #1 used an alcohol wipe, which was not approved for this purpose. This practice was observed during a blood glucose check, and Nurse #1 stated she had always used alcohol wipes and was unaware of the need for an EPA-registered disinfectant. The shared glucometer was used for multiple residents on the unit, and the improper cleaning method was used between each resident. Additionally, the Wound Care Nurse did not adhere to the facility's hand hygiene policy during wound care for a resident. After cleansing a sacral wound, the nurse failed to change gloves and perform hand hygiene before applying a new dressing, instead using the same gloves to handle both the wound and the dressing materials. The nurse later acknowledged that hand hygiene and glove change should have occurred between these steps to prevent cross-contamination but did not perform them during the observed procedure. A separate incident involved a nurse aide who placed soiled linen, including towels and a gown, directly on the floor of a resident's room after providing a bath, rather than bagging the items as required by facility policy. The aide admitted to being aware of the correct procedure and having bags available but did not use them. The Director of Nursing confirmed that soiled linen should never be placed on the floor and should always be bagged immediately to prevent the spread of germs.
Removal Plan
- The Facility Consultant completed a medical record audit of all residents, including Resident #34, Resident #92, and Resident #97, who received blood glucose checks to identify any diagnosed blood-borne pathogen infections.
- The unit managers and the treatment nurse completed the cleaning and disinfecting of all resident glucometers in accordance with the manufacturer’s instructions.
- The Director of Nursing, Assistant Director of Nursing, Treatment Nurse and Unit Managers initiated, in person, education with all nurses and medication aides regarding the importance of following facility and manufacturer’s instructions for cleaning and disinfecting a shared glucometer.
- Any nurse or medication aide who has not worked or received the in-service will receive the education prior to the next scheduled work shift.
- All newly hired nurses or medication aides including agency, will be in-serviced by the Director of Nursing, Assistant Director of Nursing or Unit Managers during orientation regarding the importance of following facility and manufacturer’s instructions for cleaning and disinfecting a shared glucometer.
- The Director of Nursing (DON), Assistant Director of Nursing (ADON), and Unit Managers initiated in-person return demonstrations of properly cleaning and disinfecting glucometers with all nurses and medication aides including agency.
- Any nurse or medication aide who does not successfully pass the return demonstration will be immediately re-educated and will be required to repeat the return demonstration until successful demonstration is achieved.
- Staff who have not completed the return demonstrations will complete it prior to their next scheduled work shift.
- The Director of Nursing, Assistant Director of Nursing and Unit Managers initiated in person quizzes with all nurses and medication aides, including agency to validate knowledge and understanding of the importance of following facility and manufacturer’s instructions for cleaning and disinfecting a shared glucometer.
- Any nurse or medication aide that does not successfully pass the quiz will be immediately re-educated and will be required to retake the quiz at the time of administration until a successful passing score is achieved.
- Any nurse or medication aide who has not completed the quiz will complete it prior to their next scheduled work shift.
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