Below average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Alamance Health Care Center during CMS and state inspections, most recent first.
A facility failed to keep enough linens available for resident hygiene and comfort. Multiple cognitively intact residents on different halls reported no towels, washcloths, sheets, or gowns when needed for bathing or daily care, with some using wipes, pillowcases, bibs, or partial towels instead. NAs confirmed the shortages, said baths and showers were delayed, and reported laundry staffing gaps and limited access to backup supplies. The EVS Director stated the last washcloths had been removed from stock and more could only be ordered at month-end.
Failure to follow the abuse reporting and protection policy after an allegation of staff-to-resident physical abuse involving a nurse and a resident with multiple serious diagnoses. Staff described seeing the nurse pull and drag the resident in the hallway, but concerns were not reported to leadership right away because of fear of retaliation and belief the nurse was a valued employee. The facility did not learn of the allegation until a CNA brought photographs to the Administrator and DON, and the nurse was suspended only after that disclosure.
Inaccurate diagnosis documented in a resident record. A resident with CAD, MI, HTN, DM2, CHF, and CKD had Parkinson's disease listed as the principal admitting diagnosis even though it was not supported by the medical history. The MDS nurse entered the diagnosis based on an alert and a follow-up note, and an NP later acknowledged the diagnosis was entered in error and then carried forward in subsequent notes. The resident's family reported a receiving SNF refused admission because the transfer paperwork listed Parkinson's disease.
Failure to Follow EBP During Incontinence Care: Staff provided incontinence care to a resident on EBP for a feeding tube while wearing only gloves and not gowns, despite EBP signage and PPE being posted at the room door. Two NAs stated they forgot to put on gowns, and a third NA later did the same while saying she was in a hurry. The DON and Administrator stated staff were expected to follow the posted EBP requirements.
A resident with moderate cognitive impairment and total dependence for ADLs had his smartphone go missing, and an unauthorized $492 transfer was made from his money transfer app account. Staff and family reported the resident used the phone to access contacts, bank accounts, a money transfer app, and an on-demand delivery app, and interviews showed multiple staff had previously used the phone to make purchases for him with his permission. The phone was not recovered, and the resident’s family reported the device was unsecured and accessible to anyone.
Failure to Send Transfer/Discharge Notices to Ombudsman: The facility did not send required transfer/discharge notices to the Regional Ombudsman for three residents reviewed. One resident was sent to the hospital, another was transferred to an acute care hospital, and a third resident with severe cognitive impairment, muscle wasting, and HTN was discharged home with his RP. Staff stated they were unaware of the requirement or had not begun sending the notices, and the Ombudsman confirmed the notices were not received.
A resident with a stage 4 sacral PU, osteomyelitis, quadriplegia, and a tracheostomy had a wound vacuum connected to his sacral dressing, but staff observed the device sitting on the floor. The assigned nurse did not know why it was there, and an NA noted it was unusual but did not move or report it. Other NAs said they had seen the device on the floor on other occasions. The DON, wound nurse, wound NP, and Medical Director all stated the device should not be on the floor because it was part of the resident’s sterile wound dressing.
A resident with left hand contracture, muscle weakness, and a stroke history had OT documentation recommending continued use of a resting left hand splint, but no physician order, MAR documentation, or care plan entry was in place for nursing to implement it. Observations showed no splint applied or available in the room, and OT, Rehab, the Medical Director, and the DON all indicated the therapy recommendation was not communicated into orders for staff to follow.
A dependent resident with quadriplegia and a stage 4 pressure ulcer fell out of bed while on a rotating air mattress used for pressure relief. Staff and the resident reported he often slid to one side and had to be straightened, and the resident stated he was left near the edge of the bed rather than centered. He was found on the floor with facial bleeding and a laceration above the eye, was sent to the ED, and the Medical Director called it a never event.
A resident with atrophic vaginitis had repeated missed doses of Estrace cream because the medication was ordered late, placed on hold, or unavailable due to a missing applicator. MARs and nursing notes showed multiple instances when the cream was not administered, while the QA pharmacist confirmed the pharmacy delivered the medication on several occasions. The resident, who was cognitively intact, stated she was not receiving the cream as ordered.
A deficiency was identified when multiple rooms were found with dead and active bugs, including roaches, despite ongoing pest control treatments. Staff interviews revealed that pest issues had persisted for months, with some staff using personal sprays due to ineffective pest control services. Clutter and improper food storage in resident rooms contributed to the problem, and repeated reports to management did not result in effective resolution.
Surveyors observed multiple resident rooms with sticky, dirty floors, old food and paper debris, detached or broken baseboards, and air conditioning units filled with dust, debris, and broken parts. The Housekeeping Director, Maintenance Director, and DON confirmed that cleaning and maintenance were not performed according to facility protocols, resulting in unaddressed environmental concerns throughout the facility.
A resident with impaired vision and a diagnosis of cataracts did not receive a timely ophthalmologist consultation for cataract extraction surgery as ordered. The optometrist's recommendation and physician order were not communicated to the staff responsible for scheduling, resulting in a delay until the resident repeatedly requested assistance and a new order was placed. Staff interviews confirmed a lack of awareness and a breakdown in the process for managing outside consultant recommendations.
Surveyors found that nourishment refrigerators were not properly cleaned, temperature logs were incomplete, and residents' food items were not consistently labeled or dated. Staff interviews revealed unclear responsibilities among dietary, nursing, and housekeeping teams regarding food labeling, temperature monitoring, and cleaning of the refrigerators.
A resident with limited mobility and cognitive intactness was pulled backwards in a geriatric wheelchair by a nurse aide, despite expressing discomfort and feeling undignified. The aide cited misaligned wheels as the reason but had not reported the issue, and facility leadership was unaware of the problem. This action was recognized by leadership as not respecting the resident's dignity.
A resident with severe cognitive impairment and parkinsonism, dependent on staff for ADL care, was found with excessively long and dirty fingernails despite care plans requiring staff assistance. Staff interviews revealed confusion over responsibility for nail care, and the DON confirmed that nails should have been trimmed and cleaned as needed.
A blind resident with a history of aggression threw a can of peaches at another resident, causing a laceration. The incident occurred after the blind resident believed his food was eaten by the other resident. The injured resident refused hospital treatment, and the facility classified the event as abuse.
The facility's QA process failed to implement, monitor, and revise action plans for multiple surveys, resulting in repeated deficiencies in areas such as Quality of Care, Bowel/Bladder Incontinence, Catheter, UTI, and medication management. Specific incidents included inadequate communication among staff, improper assessment and monitoring of residents, and failures in wound and catheter care.
The facility failed to store medications according to manufacturer's instructions, label medications with required information, and date an opened vial of injectable medication. Observations revealed improper storage of eye drops, loose tablets in a med cart, unlabeled Linzess capsules and inhalation solution, and an undated vial of Tuberculin PPD.
A resident with chronic diarrhea and a complex medical history experienced multiple episodes of nausea and vomiting. The facility staff failed to ensure effective communication among themselves and with providers, leading to a lack of timely intervention and the resident's eventual hospitalization for severe sepsis and a small bowel obstruction.
The facility failed to document the Advance Directives (code status) for a resident who was readmitted and assessed as cognitively intact. Despite the resident's care plan indicating a Full Code status, there was no active order in the EHR. Staff interviews confirmed that the admitting nurse missed entering the code status during the readmission process.
The facility failed to prevent a urinary catheter bag from touching the floor for a resident with a history of UTIs and pressure ulcers. Despite staff education on proper catheter bag positioning, multiple observations showed the bag either touching or partially lying on the floor, increasing the risk of infection.
Linen shortages prevented resident bathing and daily care
Penalty
Summary
The facility failed to ensure the provision and availability of linens to meet residents’ hygiene and comfort needs for 9 of 9 residents interviewed about linen availability. Multiple cognitively intact residents on Mauve one hall, Mauve two hall, and Teal Hall reported that towels, washcloths, sheets, gowns, and other linens were not available when needed for bathing or daily care. One resident stated staff used one end of a towel to bathe her and the other end to dry her because there were not enough towels, while another reported using wipes because no clean washcloths or towels were available that morning. A resident on Teal Hall stated she was lying on two pillowcases on top of a pad because the laundry did not have clean sheets, and another resident stated she had been waiting all morning for a washcloth and towel to bathe herself. Staff interviews confirmed the linen shortages and delays in laundry availability. A nurse aide on Mauve one hall stated there were no linens, washcloths, or towels available and that baths and showers would not be provided until later in the shift. Another nurse aide stated she had to prioritize which residents received linens based on therapy schedules or appointments and that additional linens might not be available until later in the day. A nurse aide working the overnight shift stated she was waiting for laundry to be completed before continuing bed baths because there were currently no towels or washcloths available. The Environmental Services Director stated that on the day of the event a laundry aide called out, laundry did not reach the hallways until around 9:20 AM, and even one missed hour affected the laundry production cycle. The Environmental Services Director also stated she had removed the last of the facility’s supply of washcloths and was only able to order more at the end of the month while still learning required quantities and budgeting. She reported that only she and the Maintenance Director had a key to the backup laundry storage room. The Administrator stated it was her expectation that linens be kept at par levels according to the building census and said the Environmental Services Director did not need to wait until the end of the month to order washcloths if supplies were needed.
Failure to Immediately Report and Protect Resident After Abuse Allegation
Penalty
Summary
The facility failed to ensure staff followed its abuse reporting and protection policy after an allegation of staff-to-resident physical abuse involving Nurse #1 and Resident #3. The facility policy effective 10/17/2024 required all employees to immediately, and no later than two hours after an allegation involving abuse or bodily injury, report suspected or witnessed abuse to the Administrator, DON, or immediate supervisor, and required immediate action to protect the patient from further injury. The investigation documentation also required evidence that immediate action was taken to protect the patient. In this case, the facility was not informed of the allegation until NA #1 met with the Administrator and DON on 5/26/2026, and protection of Resident #3 began only after Nurse #1 was suspended that day. Resident #3 was admitted with diagnoses including Parkinson's disease with dyskinesia, hemiplegia, hemiparesis, anxiety disorder, schizophrenia, intellectual disabilities, and major depressive disorder. NA #1 stated she had learned of photographs showing Nurse #1's right hand on the back of Resident #3's neck while going down the hallway, but she did not report concerns earlier because she believed staff would not believe her and had been told Nurse #1 was an asset. NA #3 reported witnessing several occasions when Nurse #1 pulled Resident #3 down the hallway and described one incident in which Nurse #1 dragged Resident #3 by the neck, but she also did not report it because she feared retaliation or suspension. Nurse #2 confirmed Nurse #1 was assigned to the hallway where Resident #3 lived, and the ADON confirmed the facility was not made aware of the allegation until NA #1 disclosed it to leadership.
Inaccurate Diagnosis Documented in Resident Record
Penalty
Summary
The facility failed to ensure accurate documentation of a medical diagnosis for one resident whose electronic record listed Parkinson's disease as the principal admitting diagnosis, even though that diagnosis was not supported by the resident's documented medical history. The resident had cumulative diagnoses including coronary artery disease, myocardial injury, hypertension, Type 2 diabetes mellitus, congestive heart failure, and chronic kidney disease. Record review showed the Parkinson's disease diagnosis was entered by the MDS nurse, who stated she relied on a web-based software alert and a follow-up note as the source for the diagnosis. Follow-up note review showed Parkinson's disease first appeared in an NP's documentation and was then carried forward into later progress notes. The NP later acknowledged the diagnosis had been entered in error and stated she did not independently add such a diagnosis without a neurology evaluation. A family member reported that when the resident was scheduled for transfer to another SNF, the receiving facility refused admission because the transfer documents listed Parkinson's disease, and the resident was returned to the originating facility after the family stated the diagnosis was incorrect.
Failure to Follow Enhanced Barrier Precautions During Incontinence Care
Penalty
Summary
The facility failed to implement its infection control policy for Enhanced Barrier Precautions when nurse aides provided incontinence care to a resident without wearing a gown. Resident #59 was observed with yellow signage outside the room indicating PPE was required, and the signage directed staff to clean hands before and after entering the room and to wear gloves and gowns for high-contact activities such as changing briefs. PPE, including gowns and gloves, was hanging on the back of the door, and the resident was identified by staff as being on EBP because of a feeding tube. During observations, Nurse Aide #1 and Nurse Aide #2 were seen completing incontinence care for Resident #59 while wearing only gloves. Nurse Aide #1 stated she knew she should have worn a gown but forgot, and Nurse Aide #2 stated she normally did not work with the resident and did not remember to put the gown on. A later observation showed Nurse Aide #3 also providing incontinence care to Resident #59 wearing only gloves, despite the EBP signage and PPE being present. Nurse Aide #3 stated she was in a hurry and forgot to put on a gown. The DON stated staff were expected to follow the EBP signage and use the proper PPE, and the Administrator stated staff were expected to follow EBP requirements during ADL and personal care, but neither could explain why staff were providing care without the appropriate PPE.
Missing Cell Phone and Unauthorized Money Transfer
Penalty
Summary
The facility failed to protect a resident from the wrongful use of his belongings and money when his cell phone went missing and an unauthorized transfer occurred from his money transfer application account. The resident was admitted with moderate cognitive impairment and was dependent on staff for assistance with all activities of daily living. He used his smartphone with staff assistance to access personal contacts, bank accounts, a voice communication application, a money transfer application, and an on-demand delivery platform. According to the record, the resident reported his cell phone missing after staff and family were unable to reach him. A search of his room and surrounding facility areas did not locate the phone. The resident’s family was notified, and law enforcement and Adult Protective Services were contacted. A police report documented the missing telephone and equipment valued at $600.00. The resident’s family later reported that the phone was not password protected and could be accessed by anyone. The resident also reported that money was missing from his money transfer application account. Review of the money transfer application company’s records showed a $492.00 transaction from the resident’s account to a mobile payment service account that did not belong to him. Staff interviews indicated that multiple staff members had used the resident’s phone to make purchases for him with his permission through the money transfer application and on-demand delivery platform. The former DON and former Administrator stated the facility’s investigation found staff had been assisting the resident with these purchases, and no further systemic measures were implemented at that time to secure resident personal property or prevent further misappropriation.
Failure to Send Transfer/Discharge Notices to Ombudsman
Penalty
Summary
The facility failed to send a copy of the Notice of Transfer/Discharge to the Regional Ombudsman for 3 residents reviewed for the discharge process. Resident #117 was sent to the hospital, and the medical record showed no documentation that the Ombudsman received the required notice. The former Discharge Planner stated she was the discharge planner in November 2025 and was not aware that a copy of the Notice of Transfer/Discharge had to be sent to the Regional Ombudsman, and the Ombudsman confirmed she did not receive it. The Administrator stated she was new to the facility and expected the facility to send the notices as required by regulation. Resident #182 was transferred to an acute care hospital, and review of the facility’s transfer/discharge records showed the discharge, but there was no documentation that the Ombudsman received the Notice of Transfer/Discharge. The Ombudsman confirmed she did not receive the notice, and the former Discharge Planner stated she was responsible for sending the notices but did not begin sending them until August 2025 and was not aware the facility was required to provide the Ombudsman with a copy. Resident #179, who had severe cognitive impairment, received skilled therapy services, and had diagnoses including muscle wasting and hypertension, was discharged home in the care of his Responsible Party. The Social Worker stated the resident would not have received a transfer/discharge notice because the RP initiated the discharge, but the Ombudsman later confirmed the facility had not sent discharge notifications, and the Administrator acknowledged the February discharge information had not been sent as it should have been.
Wound Vacuum Device Left on Floor
Penalty
Summary
The facility failed to keep a resident’s wound vacuum device off the floor. The resident was admitted with diagnoses including a stage 4 sacral pressure ulcer, osteomyelitis of the sacral bone, quadriplegia, chronic respiratory failure with tracheostomy, diabetes on insulin, and injury of the cervical spinal cord. The resident’s cognition was documented as intact, and he was dependent for all activities of daily living. His care plan addressed the pressure ulcer and osteomyelitis, and he had an order for wound care using a wound vacuum at 125 mmHg continuous therapy. During observation, the wound vacuum tubing was connected to the resident’s sacral wound dressing, but the vacuum device itself was on the floor. The assigned nurse stated she did not place it there and had not noticed it during morning care. A nursing assistant assigned to the resident also observed the device on the floor, thought it was unusual, but did not elevate it or report it to the nurse. Other nursing assistants later stated they had seen the wound vacuum on the floor on different occasions, and one said she was not sure where it should be. The DON was informed of the observation and stated the device being on the floor was a concern because it was directly connected to the resident’s sacral dressing. The wound nurse and wound NP stated the wound vacuum should not be on the floor because it was part of the resident’s sterile dressing and needed to be kept in a clean, controlled environment. The Medical Director also stated wound care items used for a wound with high infection risk should not be placed on the floor. The resident had osteomyelitis associated with the pressure ulcer, and the wound vacuum was later observed during dressing change placed off the floor.
Failure to Communicate Splint Order for Resident with Left Hand Contracture
Penalty
Summary
The facility failed to have an effective system for communicating a therapy order for a resting left hand splint to nursing staff for a resident with contracture and limited ROM. The resident was admitted with diagnoses including contracture of the left hand, muscle weakness, and cerebral infarction (stroke). An OT note dated 12/11/25 documented impaired ROM and strength in both upper extremities, functional limitations due to contractures in the left hand and elbow, and use of a resting hand splint. The OT long-term goal was for the resident to safely wear the splint on the left hand for up to 5 hours without pain, swelling, or redness to reduce progression of contracture and improve hygiene. The OT discharge summary dated 1/23/26 stated the resident had improved tolerance of the left resting hand splint to 6 hours with no complaints of pain, redness, or skin irritation, and recommended continued use of the left resting hand splint. However, physician orders from 1/23/26 through 4/28/26 contained no order to apply the splint, and the MAR had no documentation for nursing staff to sign off that the splint was applied. The care plan also had no splint-related intervention. Observations on 4/28/26 and 4/29/26 showed no resting left hand splint in place or in the room, and the resident’s left hand was contracted. OT #1 confirmed she recommended continued splint use but did not communicate the order, while the Rehab Manager, Medical Director, and DON each indicated they expected therapy staff to enter or communicate the recommendation so it could be implemented.
Dependent resident fell from bed during mattress rotation
Penalty
Summary
The facility failed to keep a dependent resident positioned in the center of his bed so that a rotating air mattress used for pressure offloading would not cause him to fall out of bed. Resident #14 was admitted with quadriplegia, had intact cognition on his admission MDS, was dependent for all activities of daily living, and had a stage 4 pressure ulcer present on admission. His care plan identified him as high risk for falls and included interventions to place items within reach and remind him to use the call light. On the night of the incident, the resident was found on the floor between the beds after staff heard him yelling for help. He was lying on his left side with blood coming from his face, and his urinary catheter had become separated from the bag. Staff placed him back in bed, noted a laceration above the eye and on the cheek, cleaned the wounds, applied dressings, initiated neurological checks, and called EMS. The resident was sent to the ED, where imaging showed no fracture and the laceration above the left brow/eyelid was closed with tissue adhesive. Interviews with nursing assistants and the resident indicated he frequently slid to one side of the bed and had to be straightened, and that he liked to sit up and lean to the right. The resident stated staff left him on the edge of the bed rather than in the middle, and he fell out when the rotating mattress moved him. The Medical Director reviewed the record and stated the resident could not move independently, that this was a never event, and that staff needed to place him appropriately in the center of the bed because he could not be placed on the edge.
Medication Administration Gaps for Estrace Cream
Penalty
Summary
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist was not met for one resident reviewed for medication administration. Resident #89 was admitted with atrophic vaginitis and had an order for Estrace Cream 0.1 mg/gm, 1 gm vaginally daily, written on 3/10/25. Review of the MAR from May 2025 through April 2026 showed multiple dates when the medication was not administered, including 5/26/25 and 5/27/25, 8/4/25, 8/5/25, 8/8/25, 8/17/25, 9/11/25, 11/19/25, 11/20/25, 11/21/25, 1/14/26, 1/15/26, 2/2/26, and 2/3/26. Progress notes documented repeated instances where the cream was ordered, on hold, or unavailable because there was no medication applicator. The record showed repeated delays and interruptions in obtaining and administering the Estrace cream. Notes written by nursing staff stated the cream was ordered from the pharmacy, followed up on, or placed on hold because there was no applicator, and one note indicated the medication would be delivered later that day. The pharmacy’s Quality Assurance Pharmacist stated the facility received 42.5 grams of Estrace cream, a 42-day supply, on multiple delivery dates during the review period. Resident #89, who was cognitively intact, confirmed she was not receiving the Estrace cream as ordered and stated that at times she still did not receive it, though she could not provide specific dates.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program in 7 out of 94 resident rooms, with pest activity observed across all four halls. Monthly and special pest control service reports from August 2024 through March 2025 documented repeated treatments for roach, ant, and fly activity in resident rooms and common areas, but no changes to the service were recommended despite ongoing pest issues. There was no pest control visit in January 2025, and subsequent reports continued to note pest activity, particularly in specific rooms. Direct observations on April 28, 2025, revealed dead and active bugs, including roaches, in multiple resident rooms, particularly in areas such as bathrooms, under air conditioning units, behind nightstands, and around closets and baseboards. In one room, clutter and improperly stored food and personal items were noted to contribute to the pest problem. Staff interviews confirmed that the pest issue had been ongoing since 2024, with some staff resorting to using their own sprays due to the ineffectiveness of the contracted pest control services. Staff also reported that clutter and food storage practices by residents exacerbated the problem, and that these issues had been repeatedly reported to management without resolution. Housekeeping and maintenance staff acknowledged the presence of pests and described challenges in cleaning and pest control due to resident behaviors and limited staffing. The Housekeeping Director and Maintenance Director both confirmed that pest control companies had been contacted regularly, and that certain rooms required special attention due to hoarding and clutter. Despite these efforts, the visibility of pests persisted, and the Director of Nursing confirmed that environmental concerns in resident rooms remained unaddressed at the time of the survey.
Failure to Maintain Cleanliness and Environmental Safety in Resident Rooms
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment for residents, as evidenced by multiple observations of unclean and poorly maintained resident rooms across all facility halls. Surveyors found sticky floors with brown substances, old food, and paper products under nightstands and beds, stained and dirty surfaces, and strong urine odors in several rooms. Additionally, baseboards were found to be detached, broken, or with holes exposing sheetrock, and air conditioning units in numerous rooms had significant dust and debris buildup, with some units containing food, paper products, and broken slats with sharp edges. These conditions were directly observed by surveyors during their inspection of 13 resident rooms. Interviews with the Housekeeping Director and Maintenance Director confirmed that cleaning and maintenance tasks were not performed according to the facility's established checklists and responsibilities. The Housekeeping Director acknowledged that some rooms had not been cleaned as required, and the Maintenance Director confirmed the presence of dirty air conditioning units and unrepaired baseboards. The DON also confirmed awareness of the environmental concerns and the lack of proper cleaning and maintenance in resident rooms at the time of the survey.
Failure to Schedule Ophthalmologist Consultation for Cataract Surgery
Penalty
Summary
A deficiency occurred when the facility failed to schedule an ophthalmologist consultation for cataract extraction surgery as ordered for a resident with impaired vision. The resident, who was cognitively intact and used glasses, had a diagnosis of age-related cataracts in both eyes, with the right eye causing blurred vision and increasing fall risk. An optometrist recommended in November that the facility select a local ophthalmologist for cataract extraction, and the Medical Director initialed the consultation. However, there was no documented appointment with an ophthalmologist or follow-up on the recommendation until a new order was placed in March of the following year. Interviews with staff revealed that the optometrist's recommendation was not communicated to the appropriate personnel responsible for scheduling appointments. The Unit Manager, Unit Secretary, and Director of Nursing were all unaware of the initial referral, and the new Social Worker stated that the system for managing outside consultant recommendations was still being developed. The resident reported having to repeatedly request assistance before finally being seen by an ophthalmologist. The deficiency was attributed to a breakdown in communication and follow-up regarding the optometrist's recommendation and physician order.
Failure to Maintain Cleanliness and Proper Food Labeling in Nourishment Refrigerators
Penalty
Summary
The facility failed to maintain proper food storage and sanitation practices in two of three nourishment refrigerators located on the Teal and Mauve 1 hallways. Observations revealed that temperature logs for the refrigerators and freezers were not documented for several days, and the interiors of the refrigerators contained water, yellowish-red stains, and light yellowish stains. Additionally, there were multiple instances of unlabeled and undated food items, including a protein shake bottle, a bag of raw seafood mix, and an open fast-food milkshake container. The raw seafood mix was identified as belonging to a resident who had ordered it from a grocery store, but it was not labeled or dated as required. Interviews with staff indicated confusion and lack of clarity regarding responsibilities for labeling food, recording temperatures, and cleaning the refrigerators. The Dietary Manager stated that nursing staff were responsible for labeling residents' food, while dietary staff were to record temperatures. Housekeeping staff were reported to clean the nourishment refrigerators weekly, but the Housekeeping Manager clarified that their staff only cleaned the exterior and not the inside of the refrigerators. The Administrator confirmed that all three departments—Dietary, Nursing, and Housekeeping—were responsible for keeping the refrigerators clean and ensuring that no raw food was stored in them, and that all residents' foods should be labeled with names and dates.
Resident Dignity Compromised by Improper Wheelchair Handling
Penalty
Summary
A deficiency occurred when a nurse aide (NA) pulled a resident's geriatric wheelchair backwards down the hall from the nurses' station to the dining room, a distance of approximately 50 yards. The resident, who had a history of cerebral infarction resulting in limited range of motion on one side and was dependent on staff for wheelchair locomotion, was cognitively intact and reported feeling undignified and as if she was being treated like a 'crazy person.' The resident expressed that she did not want to go to the dining room and specifically disliked being pulled backwards, noting that this NA was the only staff member who moved her in this manner. The NA stated that she pulled the wheelchair backwards because the wheels were misaligned, making it difficult to push the chair forward as trained. However, she had not reported the issue to maintenance, and there were no work orders on file to repair the wheelchair. Facility leadership, including the Nurse Consultant and Administrator, were unaware of the wheelchair's condition and confirmed that staff were expected to push, not pull, wheelchairs. The act of pulling the wheelchair backwards was acknowledged by facility leadership as undignified treatment.
Failure to Trim and Clean Dependent Resident's Fingernails
Penalty
Summary
A deficiency was identified when a resident, admitted with adult failure to thrive and parkinsonism and assessed as severely cognitively impaired, was observed to have fingernails that were excessively long, measuring approximately three-fourths to one inch. The resident was dependent on staff for activities of daily living (ADL) care, including personal hygiene, and required substantial to maximum assistance. During observations, the resident's fingernails were noted to have black debris and food particles underneath, particularly after eating with her hands. The care plan indicated the need for staff assistance with ADLs due to the resident's cognitive and physical limitations. Interviews with staff revealed that nurse aides were responsible for trimming fingernails unless the resident had diabetes, in which case the nurse would perform the task. The assigned nurse aide acknowledged noticing the long fingernails and reported it to the nurse, but the nurse had not observed the issue. The Director of Nursing confirmed that fingernails should be checked and trimmed as needed during showers or bed baths, and that the resident's nails should have been trimmed and cleaned by staff. The failure to provide this care resulted in the resident having untrimmed and unclean fingernails despite being dependent on staff for hygiene.
Resident-to-Resident Abuse Involving a Blind Resident
Penalty
Summary
The facility failed to protect a resident's right to be free from abuse when one resident struck another with a can of peaches. The incident involved two residents, one of whom was blind and had a history of verbal behavioral symptoms and aggression. The blind resident, believing that his food had been eaten by his roommate, threw a can of peaches in frustration, which resulted in the can striking the other resident on the head, causing a laceration. The resident who was struck had a recent admission to the facility and was cognitively intact with no behaviors noted. The incident occurred when the blind resident, who was unable to see where he was throwing the object, acted out of frustration after suspecting his food had been taken. The altercation led to the injured resident sustaining a laceration above the right eye, which was treated on-site after the resident refused to go to the hospital. Interviews with staff and residents revealed that the blind resident had a history of being easily angered and verbally aggressive, with a care plan that noted behaviors related to past substance abuse. The incident was classified as resident abuse, and the facility's response included separating the residents and notifying relevant authorities. However, the deficiency highlights a failure to prevent resident-to-resident abuse, particularly given the known behavioral history of the blind resident.
Repeated Deficiencies in Quality Assurance and Resident Care
Penalty
Summary
The facility's quality assurance (QA) process failed to implement, monitor, and revise action plans developed for multiple recertification and complaint investigation surveys. This resulted in repeated deficiencies in areas such as Quality of Care, Bowel/Bladder Incontinence, Catheter, UTI, and the labeling and storage of drugs and biologicals. Specific incidents included a resident with chronic diarrhea who experienced multiple episodes of nausea and vomiting without effective communication among staff and providers, and a diabetic resident whose need for daily bedside blood sugar monitoring was not assessed properly. Additionally, a resident with a seizure disorder had their medication dosage decreased without proper communication, leading to a seizure, hospitalization, and intubation. In another incident, the facility failed to identify the seriousness of third-degree facial burns in a resident, resulting in inadequate monitoring and medical intervention until emergency services arrived. The resident suffered severe burns, cardiac arrest, and ultimately expired. There were also failures in conducting full body skin assessments, leading to a resident being sent to the emergency department with significant swelling, excoriations, pressure ulcers, and an embedded identification band. Another resident did not receive consistent wound care and treatment order changes after a podiatry visit. The facility also failed to manage urinary catheter care properly, including preventing a catheter bag from touching the floor and addressing a resident's use of a condom catheter without a physician's order. Medication management issues were also noted, such as improper storage, labeling, and disposal of medications. These deficiencies were observed across multiple surveys, indicating a pattern of the facility's inability to sustain an effective quality assurance program.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to store medications in accordance with the manufacturer's storage instructions on two of four medication carts. Specifically, neomycin, polymyxin B, and 0.1% dexamethasone ophthalmic suspension eye drops were stored lying on their side instead of upright on the Teal South Med Cart. Additionally, two bottles of 1% prednisone acetate ophthalmic suspension eye drops were stored lying on their side in the Mauve 2 South Med Cart. Staff interviews revealed that the nurses were unaware of the proper storage requirements for these medications. Furthermore, five loose, unidentified tablets were found in the drawer of the Teal South Med Cart, which were not discarded as required by the facility's protocol for cleaning medication carts after each shift. The facility also failed to label medications with the minimum required information, including the resident's name, on two of four medication carts. Two opened bottles of Linzess capsules on the Teal South Med Cart were not labeled with the resident's name, and one of these bottles was expired. Similarly, a vial of ipratropium bromide/albuterol inhalation solution on the Mauve 2 South Med Cart was not labeled with the resident's name. Staff interviews confirmed that the nurses were aware of the labeling requirements but had not adhered to them in these instances. Additionally, the facility did not date a vial of injectable medication to determine its shortened expiration date in one of two medication storage rooms. An opened multi-dose vial of Tuberculin PPD injectable medication in the Teal Med Room was not labeled with the date it was opened, contrary to the manufacturer's instructions that it should be discarded after 30 days. The Unit Manager confirmed that the vial should have been dated when opened and discarded after 30 days if not used.
Failure to Ensure Effective Communication Among Staff and Providers
Penalty
Summary
The facility failed to ensure effective communication among staff and providers when a resident with chronic diarrhea began experiencing multiple episodes of nausea and vomiting. Despite the resident's complex medical history, including chronic osteomyelitis, heart conditions, and gastrointestinal issues, the staff did not adequately communicate these acute changes. The resident's care plan noted the risk for gastrointestinal problems and dehydration, but the staff did not take timely action to address the new symptoms or adjust the resident's medications accordingly. The resident was prescribed multiple medications, including antibiotics and digestive aids, which could have contributed to her symptoms. The staff administered the antibiotics Daptomycin and Ertapenem, despite a flagged allergy to carbapenems, without thoroughly investigating the potential risks. The resident's bowel log indicated frequent loose stools, but this information was not effectively communicated to the nurse practitioners or physicians, leading to a lack of timely intervention. Interviews with staff revealed that the resident's symptoms of nausea and vomiting were not consistently reported or addressed. The resident's condition deteriorated over several days, culminating in a hospital transfer where she was diagnosed with severe sepsis and a small bowel obstruction. The lack of effective communication and timely intervention contributed to the resident's worsening condition and eventual hospitalization.
Failure to Document Advance Directives in Resident's Record
Penalty
Summary
The facility failed to have Advance Directives (code status) documented in the resident's record for one resident reviewed for Advance Directives. Resident #44, who was cognitively intact, was readmitted to the facility and had a care plan indicating a Full Code status. However, there was no active order for code status in the resident's Electronic Health Record (EHR). Interviews with various staff members, including a nurse, social worker, RN supervisor, Nurse Practitioner, and the Director of Nursing (DON), confirmed that the code status was not documented in the EHR as required. The RN supervisor and DON indicated that the admitting nurse missed entering the code status during the readmission process, resulting in the absence of a physician's order for the resident's code status. The social worker mentioned that the Advance Directives were discussed with the resident during the baseline care plan meeting at readmission, and there was no change in the resident's code status. However, the social worker did not notify the nursing staff since there was no change. The RN supervisor and Nurse Practitioner both stated that the admitting nurse should review and enter the code status in the EHR, but this step was missed. The DON confirmed that the code status should have been entered in the resident's medical record at admission or readmission, but it was overlooked during the recent hospitalization readmission process.
Failure to Prevent Urinary Catheter Bag from Touching the Floor
Penalty
Summary
The facility failed to keep a urinary catheter bag from touching the floor, which increases the risk of infection for a resident with a history of urinary tract infections (UTIs). Resident #129, who has Stage 4 pressure ulcers and a history of repeated UTIs, was observed multiple times with her urinary catheter bag either touching or partially lying on the floor. These observations occurred on several occasions, including when the resident was lying in bed. The resident's care plan indicated the need for a urinary catheter due to her wounds, and her most recent Minimum Data Set (MDS) assessment confirmed she was cognitively intact but dependent on staff for most Activities of Daily Living (ADLs). Despite this, the catheter bag was repeatedly found in an improper position, increasing the risk of infection. During an interview, Nurse #5 acknowledged that the catheter bag should not be on the floor and attributed the issue to the resident lowering her electric bed, which she could control independently. The resident herself was unaware that lowering her bed could cause the catheter bag to touch the floor. The facility's Registered Nurse (RN) Supervisor confirmed that staff were educated to ensure catheter bags were not on the floor and that beds should be raised to prevent this. However, the repeated observations of the catheter bag on the floor indicate a failure to consistently follow these guidelines, leading to the deficiency noted in the report.
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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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Nursing homes near Burlington
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| White Oak Manor - Burlington | 1 mi | ★★★★★ | 3 | 0 |
| Peak Resources - Alamance, Inc | 1.6 mi | ★★★★★ | 4 | 0 |
| Edgewood Place At The Village At Brookwood | 3.4 mi | ★★★★★ | 0 | 0 |
| Liberty Commons Nursing & Rehabilitation Center Of | 5.9 mi | ★★★★★ | 2 | 0 |
| Compass Healthcare And Rehab Hawfields, Inc. | 6.6 mi | ★★★★★ | 10 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.