Above average — CMS composite of the measures below.
A standard survey is most likely before around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Katherine's Place At Wedington during CMS and state inspections, most recent first.
Failure to Provide Incontinent Care and Rounding: A cognitively intact resident who needed substantial to maximal help with toileting hygiene was left in a wet brief throughout an overnight shift. CNAs reported they did not check or change the resident, and the resident was found the next morning soaking wet with urine saturated linens, urine on the floor, and bleeding on the buttocks from being so wet.
Hand Hygiene Not Maintained During Perineal Care: A resident with severe cognitive impairment, bowel incontinence, and limited mobility was observed receiving perineal care from two CNAs and two LPNs. One CNA handled linens and opened a drawer to search for cream while still wearing contaminated gloves, then continued assisting with clean tasks without removing the soiled gloves or performing hand hygiene. The CNA stated she did not change gloves because she was nervous, and staff interviews and facility policy confirmed hand hygiene is required after contact with bodily fluids and during perineal care.
A resident with no cognitive impairment alleged that a CNA made a derogatory comment during care, which was reported internally to the AIT and DON. The DON conducted an internal investigation and determined the comment was not directed at the resident, but the facility did not report the allegation to the State Licensing Agency as required by policy. This failure to report the allegation constituted a deficiency in abuse reporting procedures.
The facility failed to ensure proper hand hygiene and glove use among dietary staff, leading to potential cross-contamination of food items. Observations revealed uncovered meat items in the freezer and improper handling of food by dietary employees without washing hands or changing gloves after touching contaminated surfaces. This non-compliance with hand hygiene protocols had the potential to affect 103 residents.
A facility failed to ensure residents received dignified dining assistance. A CNA was observed standing while feeding a cognitively impaired resident, contrary to the facility's policy that staff should sit and maintain eye contact. The ADON confirmed that staff have stools to facilitate this practice.
The facility failed to update care plans for three residents to include high-risk medications and oxygen usage. Despite physician's orders, the care plans did not address the necessary interventions for anticoagulants, insulin, antianxiety medication, diuretics, opioids, and oxygen. Interviews with staff confirmed the oversight and the lack of a policy for care plan initiation.
The facility failed to update the care plans of three residents to reflect current physician orders, leading to discrepancies in medication and dialysis instructions. Interviews with an LPN and the DON confirmed the care plans were not revised, and the facility lacked a policy for care plan revision.
The facility failed to follow physician's orders for wound care during scheduled dressing changes for two residents. The LPN did not pat dry the wound beds as ordered, which was confirmed during interviews. The DON acknowledged the importance of following orders to ensure proper wound healing.
The facility failed to follow the planned menu and ensure adequate food portions for residents on pureed diets. A dietary employee prepared insufficient servings of bread pudding, and turnip greens were served instead of mixed greens due to limited availability. These actions affected the nutritional needs of residents on mechanical soft and pureed diets.
The facility failed to ensure meals were served at acceptable temperatures. Observations showed unheated food carts delivering trays with milk at 50-57 degrees Fahrenheit and melted ice cream. This affected multiple residents across different halls.
The facility failed to ensure that pureed food items were blended to a smooth, lump-free consistency, posing a risk to residents requiring pureed diets. Observations revealed lumpy and improperly blended pureed bread, vegetables, beef steak fingers, and sausage, which was confirmed by the Dietary Supervisor.
The facility failed to ensure proper hand hygiene and infection control during wound care for two residents. An LPN was observed not performing hand sanitation before and during wound care, using germicidal wipes incorrectly, and not following proper procedures for disinfecting equipment. The DON confirmed inconsistencies in infection control practices and lack of in-service training for the treatment nurse.
The facility failed to send a bed hold notification to a resident and their representative following a hospital transfer. The Business Office Manager confirmed that the system did not generate the notification due to the transfer occurring over the weekend. Both the BOM and the Administrator acknowledged the lapse in the process, which typically involves sending the notification within 24 hours.
A resident with Parkinson's disease and muscle wasting was observed multiple times with a brown substance under their fingernails, indicating a failure in ADL care. Interviews with staff revealed confusion and inconsistency in nail care responsibilities, leading to the deficiency.
A facility failed to follow physician's orders for changing oxygen tubing and humidifier bottles for a resident with moderate cognitive impairment. Despite orders to change the setup weekly, observations revealed that the tubing and bottle were not changed as required, and the humidifier bottle was empty. The MAR indicated the change was completed, but staff confirmed it was not done.
The facility failed to ensure a monthly medication regimen review for a resident, as required by policy. The DON confirmed that the consultant pharmacist did not complete the review for January 2024, which is essential to prevent side effects or accidents.
Failure to Provide Incontinent Care and Rounding
Penalty
Summary
The facility failed to provide incontinent care during an eight-hour night shift for one cognitively intact resident who required substantial to maximal assistance with toileting hygiene. The resident’s care plan directed staff to anticipate and meet the resident’s needs and to keep the resident’s skin clean and dry. The resident reported that the brief was not checked or changed during the night shift and that urine had dried on the bed from multiple incontinent episodes. During the night shift, one CNA reported that she worked with another CNA and believed the other CNA had checked the resident, but she also stated that she did not check or change the resident during that shift and was written up for not making rounds. Another CNA later reported that he did not check or change the resident during the shift, that he and his partner forgot to round on the resident, and that he slept a lot during the shift. The licensed nurse responsible for the shift stated he was not aware the CNAs had not made rounds and relied on them to do so. At the start of the day shift, staff found the resident still in bed, soaking wet, with brown rings on both sides of the bed, a brief falling apart, urine soaked through the mattress, and urine dripping onto the floor. Staff also reported that the resident had bleeding on the buttocks from being so wet and had placed a shirt between the legs to absorb urine. Another nurse observed saturated linens and reported that the resident stated they had not been changed all shift. The report also states that the resident had a history of perineal excoriation at times from incontinence.
Hand Hygiene Not Maintained During Perineal Care
Penalty
Summary
The facility failed to ensure good hand hygiene was maintained during perineal care for Resident #54. Resident #54 had diagnoses including inflammation and swelling of the kidney, urinary tract infection, and inability to voluntarily move the upper and lower body. The quarterly MDS dated 08/19/25 showed a BIMS score of 3, indicating severe cognitive impairment, and the resident was always incontinent of bowel and stool. The care plan identified bowel incontinence related to advanced disease process and decreased mobility, with interventions to check the resident every two hours, assist with toileting needs, and provide perineal care after each episode of incontinence. During observation on 09/03/2025, two CNAs and two LPNs assisted with transferring Resident #54 from a chair to bed and then with perineal care. The resident’s brief was wet, and the resident was wiped one time in one direction on the left and right side of the perineal area. While still wearing contaminated gloves, CNA #11 opened a dresser drawer and handled multiple lotion bottles to find cream for the resident’s skin. CNA #11 later assisted with positioning and linens without performing hand hygiene or removing soiled gloves, and then removed the gloves and discarded them. During interview, CNA #11 stated she did not change gloves when touching linens and opening the drawer because she was nervous, and acknowledged that not changing gloves or performing hand hygiene when moving from dirty to clean tasks can cause cross contamination. Other staff interviews and facility policies confirmed that hand hygiene is required after contact with bodily fluids and during perineal care.
Failure to Timely Report Allegation of Verbal Abuse to State Agency
Penalty
Summary
The facility failed to report an allegation of verbal abuse involving a resident to the State Licensing Agency as required by its own policy. The policy mandates that all allegations of abuse be reported immediately, but not later than two hours after the allegation is made. In this case, a resident with no cognitive impairment, who required significant assistance with activities of daily living, reported that a CNA made a derogatory comment during care. The resident stated the incident was reported to the Administrator in Training (AIT) on the same day it occurred. Interviews and record reviews confirmed that the AIT, Director of Nursing (DON), and Administrator were all made aware of the allegation. The DON conducted an internal investigation, including interviews and witness statements from the CNAs involved, and concluded that the comment was not directed at the resident but was part of a conversation between staff members. Despite this, the facility did not report the allegation to the State Licensing Agency as required by policy, because the DON and Administrator determined it was not abuse after their internal review. Further interviews revealed inconsistencies in the notification process and documentation, with the Administrator and CNA involved indicating they were not immediately informed or did not recognize the need to report the incident externally. The failure to report the allegation, regardless of the internal findings, constituted noncompliance with the facility's abuse reporting policy and regulatory requirements.
Failure to Ensure Proper Hand Hygiene and Glove Use in Dietary Department
Penalty
Summary
The facility failed to ensure proper hand hygiene and glove use among dietary staff, leading to potential cross-contamination of food items. Observations revealed that meat items in the freezer were not covered or sealed, and an opened cup containing a chocolate shake was stored in the freezer, exposing it to air and potential contamination. Additionally, dietary employees were observed handling food items without washing their hands or changing gloves after touching potentially contaminated surfaces. For instance, one employee placed condiments and plates on trays without washing hands, while another used contaminated gloves to handle bread and make bread pudding. Another employee was seen handling bread and cheese slices with contaminated gloves after touching the refrigerator door and other surfaces. The facility's policy on employee cleanliness and hand washing was not followed, as dietary staff did not wash their hands before beginning their shift, after breaks, or after handling dirty objects. This non-compliance with hand hygiene protocols was confirmed through interviews with the dietary employees, who acknowledged their failure to change gloves and wash hands as required. The deficient practice had the potential to affect 103 residents who received meals from the kitchen, posing a risk of cross-contamination and compromising food safety.
Failure to Preserve Resident Dignity During Dining Assistance
Penalty
Summary
The facility failed to ensure that residents received assistance with dining in a manner that preserved their dignity. During an observation, a CNA was seen standing while feeding a resident with severe cognitive impairment, rather than sitting to maintain eye contact and promote dignity. The CNA explained that the resident was far from her, which led to her standing. The Assistant Director of Nursing confirmed that staff are provided with stools to sit and look residents in the eyes while assisting with eating. The facility's policy on dignity emphasizes that residents should be treated with respect and their sense of well-being should be promoted at all times.
Failure to Update Care Plans for High-Risk Medications and Oxygen Usage
Penalty
Summary
The facility failed to initiate care areas and interventions on the resident care plans for oxygen usage and physician's orders for high-risk medications for three residents. Resident #13, who was admitted with atherosclerotic heart disease and type 2 diabetes mellitus, had a BIMS score of 15 indicating cognitive intactness. Despite receiving insulin injections and taking an anticoagulant, these medications were not addressed in the care plan. Similarly, Resident #15, admitted with essential hypertension, anxiety disorder, and pain, had a BIMS score of 2 indicating severe cognitive impairment. This resident's care plan did not address the use of antianxiety medication, diuretics, or opioids, despite physician's orders for these medications. Resident #99, with a BIMS score of 11 indicating moderate cognitive impairment, was on oxygen at admission and while a resident, but this was not included in the care plan either. Interviews with the RN, LPN, and DON confirmed that the care plans for these residents did not include the necessary interventions for high-risk medications and oxygen usage. The DON and LPN stated that medication orders are reviewed during daily start-up meetings and should be added to the care plan the same day. However, this process was not followed, leading to the deficiencies. Additionally, the DON confirmed that the facility did not have a policy for care plan initiation for care areas on the care plan.
Failure to Revise Care Plans to Reflect Current Physician Orders
Penalty
Summary
The facility failed to revise the care plans of three residents to reflect current physician orders. Resident #13, who was cognitively intact, had a care plan that did not include the updated order for Hydrocodone-Acetaminophen for severe pain, instead listing an outdated order for Tramadol. Resident #15, with severe cognitive impairment, had a care plan that did not reflect the current orders for Remeron and Xarelto, instead listing outdated orders for escitalopram and Warfarin. Resident #46, who was cognitively intact and required hemodialysis, had a care plan that listed incorrect dialysis center information and times, which did not match the current physician's orders. Interviews with LPN #3 and the Director of Nursing (DON) confirmed that the care plans had not been updated to reflect the new physician orders. Both LPN #3 and the DON acknowledged the importance of accurate care plans for ensuring quality care and preventing confusion among staff. The facility did not have a policy for care plan revision, which contributed to the discrepancies found in the residents' care plans.
Failure to Follow Physician's Orders for Wound Care
Penalty
Summary
The facility failed to ensure that the physician's orders for wound care were followed during scheduled dressing changes for two residents. Resident #4, who had a pressure ulcer on the left heel, did not have the wound bed patted dry as ordered by the physician during a dressing change. Similarly, Resident #32, who had a pressure ulcer on the back, also did not have the wound bed patted dry as per the physician's order during a dressing change. Both residents had specific orders for wound care that included cleansing the wound, patting it dry, and then applying the appropriate dressing, but these steps were not fully adhered to by the LPN performing the care. During interviews, the LPN confirmed that the wound beds were not patted dry as ordered for both residents. The Director of Nursing also acknowledged the importance of following physician's orders to ensure proper wound healing. The facility's policy on wound care, which requires verification of a physician's order for the procedure, was not followed in these instances, leading to the deficiencies noted in the report.
Failure to Follow Planned Menu and Ensure Adequate Food Portions
Penalty
Summary
The facility failed to ensure that meals were prepared and served according to the planned written menu to meet the nutritional needs of the residents. During an observation on 05/15/2024, it was noted that a dietary employee used a #8 scoop to prepare six servings of bread pudding for ten residents on pureed diets, resulting in insufficient portions. The dietary employee admitted to the surveyor that some of the dessert had to be discarded due to burnt edges caused by an oven that was not functioning properly. This led to a shortage of the required food for the residents on pureed diets. Additionally, the facility served turnip greens instead of the mixed greens specified on the menu. When questioned, the dietary supervisor stated that only turnip greens were available. The facility's recipe for mixed greens included both collard greens and turnip greens, but the substitution was not in accordance with the planned menu. These actions and inactions had the potential to affect the nutritional needs of 29 residents on mechanical soft diets and 9 residents on pureed diets.
Failure to Maintain Proper Food Temperatures
Penalty
Summary
The facility failed to ensure meals were served in a method that maintained the appearance of cold products and at temperatures that were acceptable to the residents. During an observation on 05/15/2024 at 12:17 PM, an unheated food cart containing 11 trays for lunch was delivered to the 100 Hall by a CNA. By 12:39 PM, after the last resident was served, the temperature of the food items on the test tray was taken. The milk was at 50 degrees Fahrenheit, the regular chicken with gravy was at 113.9 degrees Fahrenheit, and the ice cream was melted. The CNA confirmed the ice cream was melted when asked by the Surveyor. Similarly, on the same day at 12:46 PM, another unheated food cart containing 18 trays for the 300 and 400 Halls' lunch was delivered to the 400 Hall by another CNA. By 01:05 PM, after the last resident was served, the temperature of the food items on the test tray was taken. The milk was at 57 degrees Fahrenheit, and the ice cream was melted and running. The CNA confirmed the ice cream was too melted and running when asked by the Surveyor. This deficiency had the potential to affect multiple residents across different halls who received meal trays in their rooms.
Improper Consistency of Pureed Food Items
Penalty
Summary
The facility failed to ensure that pureed food items were blended to a smooth, lump-free consistency, which is essential to minimize the risk of choking or other complications for residents requiring pureed diets. During observations on 05/14/2024, a dietary employee was seen placing dinner rolls into a blender with whole milk and pureeing them. The resulting mixture was lumpy and not smooth. Additionally, pureed vegetables were observed to be runny, and pureed beef steak fingers were lumpy with visible pieces of meat. These observations were confirmed by the Dietary Supervisor, who acknowledged the improper consistency of the pureed food items. Further observations on 05/15/2024 during breakfast service revealed similar issues. Pureed sausage and pureed bread served to residents on pureed diets were lumpy and not smooth, with visible pieces of sausage in the mixture. The Dietary Supervisor again confirmed these findings, stating that the pureed sausage should have been blended longer and that the pureed bread was sticky and lumpy. These deficiencies had the potential to affect nine residents who required pureed diets.
Failure to Ensure Proper Hand Hygiene and Infection Control During Wound Care
Penalty
Summary
The facility failed to ensure proper hand hygiene was performed before and during wound care, leading to potential cross-contamination. During an observation, an LPN was seen donning gloves without performing hand sanitation and changing gloves multiple times without sanitizing hands. This occurred while preparing for and performing wound care on a resident with a stage 3 pressure ulcer on the left heel. The LPN's actions were inconsistent with the facility's infection control policies and procedures, which require hand hygiene before and after glove changes and when gloves become contaminated. Another instance involved the same LPN performing wound care on a resident with an unstageable pressure ulcer on the back. The LPN applied gloves without hand sanitation, used germicidal wipes incorrectly, and did not follow proper procedures for disinfecting equipment. The LPN also failed to perform hand hygiene immediately after setting up a biohazard bag and before donning a gown. The LPN admitted to not receiving any in-services on wound care since taking the position and confirmed the improper use of germicidal wipes, which require a wet contact time of 2 minutes. Interviews with the Director of Nursing (DON) revealed inconsistencies in the understanding and implementation of infection control practices. The DON confirmed that hand hygiene should be performed before procedures and when gloves become contaminated. The DON also acknowledged that the facility had not conducted any in-services on wound care for the treatment nurse. Facility policies reviewed indicated the need for proper infection control training and adherence to enhanced barrier precautions to prevent the spread of multi-drug resistant organisms.
Failure to Send Bed Hold Notification After Hospital Transfer
Penalty
Summary
The facility failed to ensure a bed hold notification was sent to a resident and/or resident representative following a hospital transfer. Specifically, Resident #13 was transferred to a local hospital due to a change in condition, but no bed hold notification letter was created or sent for this transfer. The Business Office Manager (BOM) confirmed that the system, which typically generates these notifications within 24 hours, did not catch the weekend transfer, resulting in the omission. The BOM acknowledged that the bed hold letters are meant to inform the resident and their representative that a bed is available upon their return. During interviews, both the BOM and the Administrator confirmed the lapse in the process. The Administrator explained that the facility's electronic medical record software sends a notification when a resident is transferred to an outside facility, prompting the BOM to assess and provide a bed hold notification letter within 24 hours. However, this procedure was not followed for Resident #13's transfer on 03/03/2024. A review of the facility's undated Bed Hold Policy indicated that both the resident and their representative must receive a copy of the bed hold notice, which did not occur in this instance.
Failure to Maintain Resident Grooming and Hygiene
Penalty
Summary
The facility failed to provide adequate Activities of Daily Living (ADL) care to maintain good grooming and hygiene for a resident diagnosed with Parkinson's disease and muscle wasting and atrophy. The resident, who was cognitively intact with a BIMS score of 13, was observed on multiple occasions to have a brown substance underneath their fingernails. These observations were made on three separate days, indicating a consistent lack of proper nail care. Interviews with facility staff, including a Certified Nursing Assistant (CNA) and a Licensed Practical Nurse (LPN), revealed that there was confusion and inconsistency regarding the responsibility for cleaning and trimming residents' nails. The CNA stated that shower aides and CNAs were responsible for cleaning nails, while nurses were responsible for trimming them. However, there was no clear protocol for notifying nurses when a resident's nails needed trimming. This lack of clear communication and responsibility led to the observed deficiency in the resident's grooming and hygiene.
Failure to Follow Physician's Orders for Oxygen Tubing and Humidifier Bottle Changes
Penalty
Summary
The facility failed to ensure that physician's orders for changing oxygen tubing and humidifier bottles were followed for Resident #99. The resident, who had moderate cognitive impairment and was on oxygen since admission, had an order to change and date the oxygen tubing and humidifier bottle every week. However, observations on multiple days revealed that the tubing and humidifier bottle were not changed as required. Specifically, the tubing and bottle were dated 05/05/2024, and were observed to be unchanged and the humidifier bottle was empty on 05/13/2024, 05/14/2024, and 05/15/2024, despite the MAR indicating that the change was completed on 05/12/2024. During an interview, RN #1 confirmed that the oxygen setup was not changed as required and that the humidifier bottle was empty. The DON also confirmed that the MAR was marked as completed but the actual change was not done. The DON stated that the oxygen setup should be changed every 7 days to prevent infections and that this task is the responsibility of the nurse assigned to the resident. The failure to follow the physician's orders and the facility's protocol for changing the oxygen setup led to this deficiency.
Failure to Complete Monthly Medication Regimen Review
Penalty
Summary
The facility failed to ensure a medication regimen review was completed monthly for a resident reviewed for unnecessary medication review. The resident was admitted on October 13, 2023, and a review of the electronic medical record on May 15, 2024, indicated there was no medication regimen review for January 2024. The Director of Nursing (DON) confirmed during an interview on May 16, 2024, that the consultant pharmacist did not complete the medication review for January 2024. The DON acknowledged the importance of the medication regimen review in preventing side effects or accidents and stated that it is the responsibility of the consultant pharmacists to complete these reviews monthly. The facility's policy, dated April 2007, requires a documented review of each resident's medication regimen at least monthly, which was not adhered to in this case.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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| The Maples At Har-ber Meadows | 7.4 mi | ★★★★★ | 2 | 0 |
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