Above average — CMS composite of the measures below.
The next survey window likely opens around March 2027
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 Autumn Care Of Salisbury during CMS and state inspections, most recent first.
Surveyors found that the facility failed to properly label and date multiple food items stored in the walk-in freezer, including french fries, chicken breasts, sausages, hush puppies, baguettes, gluten-free bread, and a chocolate cream pie. Some items had been removed from original packaging and placed in resealable bags without any labeling, while others in original packaging lacked open or expiration dates. The Dietary Manager stated all freezer items should be labeled and dated when opened or repackaged, and staff had been educated on these requirements. A cook’s assistant and a cook reported performing weekly freezer audits, but one focused only on expired items and did not check labeling, and audits were not documented. The Administrator reported she was unaware that open food items were not being properly dated, although a prior audit had already identified unlabeled or uncovered items in the freezer.
The facility failed to secure cords from wall‑mounted televisions in multiple rooms on one hall after a grievance reported that the cords posed a tripping hazard. An audit identified numerous rooms needing cord securement, and a purchase order for cord securement kits was approved, but subsequent surveyor observations found that televisions in several rooms still had power and auxiliary cords hanging 2–3 feet off the floor, with slack that required being pushed aside to pass between the bed and the cords. The Maintenance Director acknowledged awareness of the issue and ordering kits but could not recall their installation or status, and the Administrator reported she had been informed by a prior Administrator that investigations were completed and corrections made, and was unaware that the cords remained unsecured.
A resident’s advance directive and code status were not documented consistently throughout the EHR and care plan. The resident was initially admitted as full code, but after a hospitalization, hospital documentation and an active physician order reflected DNR status. Despite this, the care plan, Care Conference Summary, and EHR demographic tab continued to list the resident as full code. The POA reported the resident’s preferences had changed over time and believed the resident was full code, while the Social Worker, MDS Nurse, and NP reported that during a care plan meeting the POA agreed the resident would remain DNR. The Social Worker acknowledged she did not update the care plan or EHR code status at the time of the meeting, leading to the discrepancy, and leadership staff were unaware that the physician order and other documentation did not match.
Two residents with gastrostomy tubes were affected by failures in tube feeding practices. For one resident with severe cognitive impairment, surveyors observed a soiled bag in the room containing two used enteral feeding tube decloggers with dried residue, despite manufacturer labeling that the devices were single-use only; staff interviews showed inconsistent understanding, with some nurses believing the decloggers could be reused. For another cognitively intact resident who received all nutrition via tube feeding and had diabetes, the MAR reflected an order and documentation for Diabetasource 1.2 at a continuous rate, but observation showed that IsoSource 1.5 was actually infusing. The nurse who hung the feeding reported she assumed IsoSource and Diabetasource were equivalent because they were made by the same manufacturer, and therefore did not follow the specific physician order for the diabetic-appropriate formula.
A resident with a suprapubic catheter had an after-visit summary and nursing note indicating a required follow-up urology appointment for routine catheter replacement, but this appointment was not communicated to the Transportation Coordinator and was never scheduled. The resident later reported that the catheter had not been changed since the initial urology visit and complained of lower abdominal soreness, believing it was related to the overdue catheter change. A nurse documented the resident’s concerns, contacted the Transportation Coordinator to arrange a new appointment, and offered a PRN catheter change, which the resident refused, preferring the urologist. The urologist subsequently confirmed that the resident had missed the scheduled follow-up and stated that monthly catheter replacement was necessary to prevent infection and tissue breakdown, and that missing the appointment placed the resident at high risk for harm. The acting DON and Administrator reported they were unaware of the missed appointment, and the Administrator noted that an agency nurse may not have followed the established process for notifying the Transportation Coordinator about follow-up visits.
A resident with dementia and hemiplegia repeatedly indicated that a male NA had hit her face, while multiple staff and the resident’s representative observed her crying and noted redness, swelling, or possible bruising on one side of her face. Staff reported the allegation to the Administrator and Unit Manager and wrote statements, but no abuse allegation or related assessment was documented in the medical record, and the NP, SW, ADON, and DON were not promptly notified or formally involved. The Administrator briefly questioned the resident, demonstrated how an arm might rest against the resident’s jaw during incontinence care, concluded the allegation was not valid due to the resident’s cognition, did not submit a 24‑hour abuse report, and did not suspend or interview the alleged perpetrator, who continued working multiple shifts. These actions and inactions show the facility did not follow its abuse policy for immediate reporting, investigation, documentation, and protection of the resident after an abuse allegation.
The facility failed to label and date leftover food, remove spoiled items, and prevent staff food storage in resident nourishment room refrigerators. Observations revealed unlabeled and undated food items, including croutons, strawberries, blueberries, and a microwavable dinner tray with signs of spoilage. Additionally, a container of cream of mushroom soup with an expired discard date was found in the walk-in cooler. Staff responsible for daily checks admitted to lapses in protocol.
Three residents did not receive their scheduled showers due to miscommunication involving an agency NA, who was incorrectly informed that no showers were scheduled for the hall. This led to the residents' preferences being disregarded, causing them distress.
Two residents receiving enteral feedings had their syringes improperly stored with plungers inside, risking bacterial growth. Nurses were unaware of the correct storage procedure, which was confirmed by the DON and acknowledged by the Administrator.
The facility failed to maintain clean air intake filters on oxygen concentrators for two residents requiring oxygen therapy. Observations revealed significant dust accumulation on the filters, and staff interviews indicated confusion over cleaning responsibilities. The DON and Administrator confirmed that nursing staff should clean the filters weekly, but this was not being done.
A resident with Parkinson's Disease experienced a grievance related to medication administration that was not promptly resolved by the facility. The resident's Responsible Party filed a grievance expressing concerns about the unavailability of medications and preferred email communication, which was not accommodated by the facility. The DON's attempts to contact the Responsible Party by phone were unsuccessful, and the Administrator did not pursue the grievance further, leaving the issue unresolved.
A resident with cognitive impairments became agitated during care, leading to an incident where one nurse aide allegedly slapped the resident while another held the resident's hands. The resident, who had a history of aggressive behavior, was not protected according to their care plan, resulting in a deficiency in safeguarding the resident from abuse.
A resident in a LTC facility was subjected to inappropriate handling by two NAs during care. The resident, who was combative and verbally abusive, had their hands restrained by one NA, while the other allegedly slapped the resident on the thigh. The incident was not reported immediately, allowing the NAs to continue their shift, contrary to the facility's abuse policies.
A resident with Parkinson's disease was not transported to a scheduled neurologist appointment due to a transportation conflict at the facility. The family member had informed the facility of the appointment in advance, but alternative transportation could not be arranged, resulting in a significant delay in the resident's care. The facility's physician believed the missed appointment did not impact the resident's care, but the family member was upset about the delay.
A resident with Parkinson's disease did not receive their prescribed Carbidopa-Levodopa medication due to unavailability. Despite efforts by nursing staff to notify the pharmacy and the Director of Nursing, the medication was not delivered on time, resulting in missed doses. The Physician's Assistant and Director of Nursing were unaware of the issue, and no hold order was documented, leading to a deficiency in care.
A resident with Parkinson's disease did not receive six doses of Carbidopa-Levodopa due to medication unavailability. Despite efforts by nursing staff to resolve the issue, the medication was not delivered promptly, and there was a lack of communication and documentation regarding hold orders. The Physician's Assistant noted potential impacts on the resident's health, although no immediate harm was reported.
Improper Labeling and Dating of Frozen Food Items
Penalty
Summary
Surveyors identified a deficiency in the facility’s food storage practices in the walk-in freezer, where multiple food items were not labeled or dated in accordance with professional standards. During an initial kitchen tour with the Dietary Manager, surveyors observed a bag of french fries and a package of 25 chicken breasts that had been removed from their original packaging and placed into resealable plastic bags without any labeling, open dates, or expiration dates. Three sausages were also found removed from original packaging, placed in an unlabeled resealable plastic bag with no open or expiration date, and had visible ice crystals. Additional items in original packaging lacked required dating, including a bag of hush puppies, a bag of 30 baguettes, two packages of gluten-free bread that were only labeled with an open date but no expiration date, and a chocolate cream pie with no expiration date. In interviews, the Dietary Manager stated that all food items stored in the freezer should be labeled and dated when opened or when removed from original packaging, and discarded once expired, and that staff had previously been in-serviced on these requirements. The Cook’s Assistant reported she performed weekly freezer checks for expired items and labeling, but also stated that these audits were not documented and that a second-shift staff member had completed the prior week’s freezer audit. The Cook reported she rotated freezer audit responsibilities with the Cook’s Assistant and that, during the previous week, she checked only for expired food items and did not check for improperly labeled items, despite having received education on proper food storage and labeling. The Administrator stated she was not aware that open food items were not being labeled with appropriate dates and reported that a prior audit had already identified unlabeled or uncovered food items in the freezer.
Unsecured Wall-Mounted Television Cords Creating Tripping Hazard in Multiple Rooms
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe, easy-to-use, and comfortable environment by not securing cords from wall‑mounted televisions in multiple resident rooms on the 600 hall. A grievance filed on 4/30/25 reported that television cords from wall‑mounted televisions posed a tripping hazard. On 5/5/25, a purchase order for ten cord securement kits was approved by the former Administrator, and an in‑service education form from the same date documented that the former Administrator instructed the Maintenance Director that, although the television cords were not considered a safety concern, they should be kept close to the wall by a cord securement system or by tying up the cords. An audit completed by the Maintenance Director on 5/7/25 identified 38 rooms, including rooms 603, 604, 605, 606, 607, 608, and 609 on the 600 hall, as needing television cord securement. Despite this, surveyor observations on 3/30/26 and again on 4/2/26 showed that rooms 603, 604, 605, 606, 607, 608, and 609 still had loose television cords hanging from wall‑mounted televisions. The televisions were mounted approximately 6 feet high, with two cords hanging down and remaining 2 to 3 feet off the ground: a power cord plugged into the wall about 2 feet from the floor and an auxiliary cord dangling freely with several feet of slack between the television and a cable box. The cords hung in such a way that they had to be pushed aside to pass between the end of the bed and the cords. During interview, the Maintenance Director stated he recalled ordering the cord securement kits after the grievance and audit but did not recall installing them, did not know whether they were backordered or received, and had no completed work order for their installation. The current Administrator, who started in June 2025, reported she had been told by the former Administrator that investigations were completed and corrections made and stated she was not aware that the television cords had not been secured.
Inconsistent Documentation of Resident Code Status and Advance Directive
Penalty
Summary
The deficiency involves the facility’s failure to maintain accurate and consistent documentation of a resident’s advance directive and code status across the medical record. The resident was initially admitted as a full code, and the electronic health record (EHR) banner and care plan dated 1/9/2026 reflected full code status. The resident was later hospitalized and then readmitted, with hospital documentation and an active physician’s order dated 01/17/2026 indicating a Do Not Resuscitate (DNR) status. Despite this, multiple areas of the facility’s documentation, including the care plan, Care Conference Summary, and the demographic tab in the EHR, continued to list the resident as full code. The resident’s quarterly MDS showed severely impaired cognition, and interviews with the resident’s Power of Attorney (POA) revealed that the resident had changed preferences over time, initially choosing DNR during a hospitalization and later expressing a desire to be full code after returning to the facility. The POA stated he informed facility staff that the resident should be full code and believed the code status remained full code, and he was unaware that the code status was documented as DNR following readmission. The POA also recalled a care plan meeting in the current year but could not remember whether code status was discussed. Interviews with staff showed conflicting understandings and incomplete follow-through on documentation responsibilities. The Social Worker reported that the resident returned from the January 2026 hospitalization as DNR and that during the 01/23/2026 care plan meeting, attended by the POA, MDS Nurse, and herself, the code status was discussed and remained DNR per the POA. She acknowledged that the discrepancy between the DNR physician order and the full code entries in the care plan, Care Conference Summary, and EHR demographic tab occurred because she did not update the code status at the time of the meeting and typically completed updates days later. The MDS Nurse stated that during the same meeting the POA requested the resident remain DNR and that she informed the NP, who also reported that the POA wanted the code status to remain DNR. The Regional Nurse Consultant acting as DON and the Administrator both stated they were unaware of the discrepancy and that the expectation was that the EHR, physician orders, and care plan be consistent and updated immediately when an advance directive is initiated, changed, or maintained.
Improper Reuse of Single-Use Decloggers and Incorrect Tube Feeding Formula Administration
Penalty
Summary
Surveyors identified that single-use enteral feeding tube declogging devices were being retained and apparently reused for a resident with a gastrostomy tube, contrary to manufacturer instructions. One resident with severe cognitive impairment and a history of gastrostomy tube use was observed lying in bed with tube feeding infusing, and a soiled clear plastic bag hanging on the wall behind the head of the bed contained two long, thin plastic declogging stylets with dried tan feeding residue. The manufacturer's package in the bag clearly stated the declogger was intended for single use only. A nurse present at the time reported that night-shift staff were responsible for maintaining the decloggers and that they were used for one week, and she did not remove the soiled decloggers during that observation. On a subsequent observation, the previously seen soiled decloggers were no longer present, and the nurse reported she had removed and discarded them and hung new supplies. Multiple staff interviews revealed inconsistent understanding of the decloggers' proper use: some nurses stated they always used a new declogger and discarded it immediately after use, while another nurse who worked nights stated she believed the devices were reusable and would need to ask how many times they could be reused. The Central Supply Manager confirmed that only single-use decloggers were stocked and pointed out the manufacturer’s warning label that they should be discarded after a single use. The Unit Manager, Nurse Practitioner, and Interim DON each stated they were unaware that staff had been retaining or reusing single-use decloggers and affirmed that staff were expected to follow manufacturer instructions. Surveyors also found that another resident with a gastrostomy tube, who was cognitively intact and received all nutrition and hydration via the tube, was not administered the tube feeding formula specified in the physician’s order. The resident’s order required Diabetasource 1.2 at 80 ml/hr over 20 hours daily, with documentation on the MAR. The MAR showed that the ordered Diabetasource 1.2 feeding was signed out as started, but observation revealed the resident was actually receiving IsoSource 1.5 at 80 ml/hr, as labeled on the feeding container. The nurse who hung the feeding stated she believed IsoSource and Diabetasource were equivalent because they were from the same manufacturer and, based on that assumption, hung IsoSource 1.5 instead of the ordered Diabetasource 1.2. The Registered Dietitian and Medical Director later confirmed there are differences between the two formulas and that Diabetasource 1.2 was the appropriate formula for the resident’s diabetes diagnosis.
Failure to Schedule and Complete Ordered Urology Follow-Up for Suprapubic Catheter
Penalty
Summary
The deficiency involves the facility’s failure to ensure a follow-up urology appointment was scheduled and completed as ordered for a cognitively intact resident with a suprapubic catheter. The resident was admitted with a suprapubic catheter that had been changed by a urologist, with written instructions in the hospital urology after-visit summary for a routine catheter replacement on 02/10/2026. Nurse documentation on the day of the hospital visit also noted that the suprapubic catheter was changed and that the resident was to return for a urology follow-up appointment on that date. However, the Transportation Coordinator reported that she was not made aware of any February follow-up appointment, had no copy of an after-visit summary highlighting a February appointment, and therefore did not schedule it. The last appointment she had documented was the initial urology visit when the catheter was changed. The resident later reported that the suprapubic catheter had not been changed since the initial urology visit and stated he had informed a nurse about the February appointment, though he could not recall which nurse. He complained of lower abdominal soreness, which he believed was related to the catheter not being changed in over a month. A nurse’s progress note documented that the resident voiced concerns about the catheter not being changed and requested a urology appointment, and that the nurse left a message for the Transportation Coordinator to arrange it. The resident had a PRN order for catheter change, and the nurse offered to change it, but the resident refused, preferring the urologist to perform the procedure. The urologist later confirmed that the resident had been scheduled for a catheter replacement on 02/10/2026 but did not attend, and that the catheter required monthly replacement to prevent infection and tissue breakdown, stating that missing the appointment placed the resident at high risk for harm. The acting DON and the Administrator both stated they were not aware of the missed appointment, and the Administrator noted that the agency nurse involved may not have been aware of the process for notifying the Transportation Coordinator.
Failure to Implement Abuse Reporting and Investigation Procedures After Resident Allegation
Penalty
Summary
The deficiency involves the facility’s failure to implement its abuse policy and procedures for reporting, investigating, and protecting a resident after an allegation of abuse. The facility’s written policy required that all allegations, suspicions, and incidents of abuse, neglect, involuntary seclusion, exploitation, misappropriation of property, and injuries of unknown origin be immediately reported to the Administrator/Abuse Coordinator, that an investigation be initiated immediately, that applicable state and local agencies be notified, and that any accused staff member be removed from resident care and placed under supervision pending the outcome of the investigation. The policy also required notification of the resident’s responsible party and attending physician, documentation of assessments and notifications in the medical record, and involvement of social services when appropriate. The resident involved was readmitted with hemiplegia, diabetes, and dementia and was assessed as moderately cognitively impaired, with clear but sometimes difficult speech, adequate vision and hearing, and a need for substantial assistance with toileting and bed mobility. On the morning after a night shift, multiple staff members, including the Activities Director, Activities Assistant, Environmental Supervisor, and nursing assistants, independently encountered the resident crying, upset, patting the left side of her face, and repeatedly saying “hit-hit” or similar phrases, sometimes naming a male staff member. Several staff observed the resident’s left cheek as pink, swollen, or puffy, and one NA reported seeing a bruise under the left eye. These staff documented handwritten statements and reported the allegation to the Administrator and Unit Manager. The resident’s representative also observed the resident upset with a pink cheek and reported that the resident indicated she had been hit. Despite these reports, the medical record contained no nursing notes documenting an allegation of abuse, and the nurse assigned to the resident on the day of the allegation stated she was told by the DON not to worry about charting because the DON would take over the investigation. The Unit Manager and another nurse reported performing skin assessments, but documentation was delayed or absent, and the Unit Manager stated she was waiting for direction from the Administrator regarding documentation. The Administrator, after a brief interaction with the resident in which she physically demonstrated how an arm might rest against the resident’s jaw during incontinence care and asked if that was what happened, concluded the allegation was not valid due to the resident’s cognitive status, did not treat it as an abuse allegation, did not suspend the alleged perpetrator, and did not complete or submit an initial 24‑hour abuse report to state agencies. The alleged staff member continued to work multiple 12‑hour shifts, was never interviewed or asked for a written statement about the incident, and social services, the NP, ADON, and DON were not promptly or formally engaged in a documented investigation. Several leaders, including the DON and ADON, later reported that they had been told by the Administrator that the incident was already determined to be related to incontinence care and that the investigation was complete, and the HR Director reported that staff were upset that an investigation had not been completed in the manner they expected. These actions and omissions demonstrate the facility’s failure to follow its own abuse policy regarding immediate reporting, thorough investigation, documentation, and protection of the resident after an allegation of abuse.
Failure to Properly Label, Date, and Store Food Items
Penalty
Summary
The facility failed to properly label and date leftover food items, remove spoiled food, and prevent staff food from being stored in resident nourishment room refrigerators. During an observation in the 600 Hall nourishment room refrigerator, a bag of croutons was found unlabeled and undated, along with a quart-sized sealed plastic bag containing strawberries and blueberries that showed discoloration and a fuzzy white substance. Additionally, a microwavable dinner tray with meat and broccoli was observed with discoloration and a fuzzy substance, and an unlabeled and undated plastic container contained a white substance resembling mold. Nurse Aide #4 admitted to placing her lunch bag in the fridge, acknowledging it should not be there. Both Nurse Aide #4 and Nurse Aide #5 were responsible for checking the nourishment rooms daily to ensure items were labeled, dated, and discarded appropriately. In the kitchen, a container of leftover cream of mushroom soup with a discard date that had already passed was found in the walk-in cooler. The Dietary Manager admitted the soup should have been discarded and was missed during checks. The Dietary Manager also revealed that Dietary Aide #1 was responsible for checking nourishment rooms over the weekend but was unavailable for an interview. The Administrator confirmed the expectation that nourishment rooms be checked daily and that food items be stored and labeled correctly.
Failure to Honor Resident Shower Preferences
Penalty
Summary
The facility failed to honor the shower preferences of three residents, all residing on the 200 hall, on 2/28/25. Resident #32, who was moderately cognitively impaired, expressed that choosing between a shower and a sponge bath was very important. Despite being scheduled for a shower on that day, she did not receive one, which upset her. Similarly, Resident #77, also moderately cognitively impaired, did not receive her scheduled shower and expressed her dissatisfaction. Resident #24, who was cognitively intact, also did not receive her scheduled shower and was upset as she expected to be offered one later in the day. The issue arose due to a miscommunication involving Nursing Assistant (NA) #3, an agency staff member who was reassigned to the 200 hall on the day in question. NA #3 reported being informed by other staff that there were no showers scheduled for the hall, leading her not to offer showers to the residents. The Director of Nursing confirmed that NA #3 received inaccurate information and that the residents should have been offered showers as per their preferences. The Administrator also confirmed the expectation that residents receive showers on their scheduled days if they desire them.
Improper Storage of Enteral Feeding Syringes
Penalty
Summary
The facility failed to properly store enteral feeding syringes for two residents, leading to potential bacterial growth and contamination. Resident #44, who was admitted with diabetes and difficulty swallowing, received a significant portion of her nutrition and fluids through enteral feedings. Observations on two consecutive days revealed that her enteral feeding flush syringe was stored with the plunger inside the syringe, which contained a thick white liquid. Nurse #1, responsible for administering medication and flushes, was unaware that the syringe should be stored separately from the plunger to prevent bacterial growth. Similarly, Resident #65, admitted with dementia and difficulty swallowing, also received a significant portion of her nutrition and fluids through enteral feedings. Observations showed that her enteral feeding flush syringe was stored improperly with the plunger inside. Nurse #2, who was about to use the syringe, was also unaware of the correct storage procedure. The Director of Nursing confirmed that the syringes should be washed and stored with the plunger separated to allow drying and prevent bacterial growth. The Administrator acknowledged the oversight by the nursing staff.
Failure to Maintain Clean Oxygen Concentrator Filters
Penalty
Summary
The facility failed to maintain clean air intake filters on oxygen concentrators for two residents, both of whom required oxygen therapy due to respiratory conditions. Resident #34, who was cognitively intact, was observed with an oxygen concentrator that had a significant layer of black dust on the air intake filter. This condition persisted over multiple observations, and staff interviews revealed a lack of clarity regarding who was responsible for cleaning the filters. Nurse #1 was unaware of the cleaning responsibilities, and the Director of Nursing indicated that the assigned nurse should clean the concentrators weekly. Similarly, Resident #44, who was moderately cognitively impaired, was also observed with a dusty air intake filter on her oxygen concentrator. Interviews with Nurse #1 and the Housekeeping Supervisor further highlighted the confusion over cleaning duties, with the Housekeeping Supervisor stating that nursing staff were responsible. The Administrator confirmed that nursing staff should clean the machines and filters at least weekly, yet this was not being done, leading to the deficiency.
Failure to Resolve Grievance Regarding Medication Administration
Penalty
Summary
The facility failed to promptly resolve a grievance filed on behalf of a resident with Parkinson's Disease, who was admitted to the facility in June 2022. The grievance was filed by the resident's Responsible Party, who expressed concerns about the resident's medication administration, specifically the unavailability of Parkinson's medications. The grievance was assigned to the Director of Nursing (DON) on the same day it was filed, but the DON documented unsuccessful attempts to contact the Responsible Party by phone, and the grievance remained unresolved. The Responsible Party reported that he had communicated his concerns through email to the Social Worker (SW) and verbally to other staff members, including the floor nurse and care planner, but received no resolution. He preferred email communication due to his busy schedule, but the facility did not accommodate this preference. The DON was unaware of the Responsible Party's preference for email communication until after her attempts to reach him by phone, and she did not follow up with an email. The Administrator and the DON did not effectively coordinate to address the grievance. The Administrator believed that email was not an appropriate medium for discussing grievances and did not attempt to contact the Responsible Party. The grievance process was further complicated by the transition of responsibilities to a new social worker, SW #2, who was not involved in handling the grievance. As a result, the facility did not make prompt efforts to resolve the grievance, leaving the Responsible Party's concerns unaddressed.
Failure to Protect Resident from Abuse During Care
Penalty
Summary
The facility failed to protect a resident's right to be free from staff-to-resident abuse. During an incident involving two nurse aides providing care to a cognitively impaired resident, the resident became agitated and combative. One of the nurse aides, NA #7, allegedly slapped the resident on the left upper thigh, while the other aide, NA #6, held the resident's hands to prevent further aggression. This incident was reported by NA #6, who stated that the resident had been aggressive and used racial slurs during the care process. The resident involved in the incident was admitted with multiple diagnoses, including cerebral infarction, major depressive disorder, and dementia, and required extensive assistance for mobility and transfers. The resident's care plan indicated a risk of adjustment issues and potential for aggressive behavior, with interventions in place to approach the resident calmly and report any mood changes. Despite these interventions, the resident's behavior during the incident was combative, and the aides continued care without following the protocol to walk away when residents are combative. The incident was reported to the facility administration, and an investigation was conducted. Statements from the involved staff members revealed discrepancies in their accounts of the event, with NA #7 denying any aggressive behavior. The facility's Director of Nursing and Administrator were informed of the incident, and NA #7 was removed from the floor pending investigation. The report highlights a failure in adhering to the resident's care plan and the facility's protocol for handling combative behavior, resulting in a deficiency in protecting the resident from abuse.
Failure to Report and Address Resident Abuse
Penalty
Summary
The facility failed to adhere to its abuse policies concerning identification, protection, and reporting, as evidenced by the incident involving Resident #3. During the incident, Nurse Aide (NA) #6 and NA #7 were providing care to Resident #3, who became combative and verbally abusive. Despite the resident's aggression, NA #6 restrained Resident #3's hands, and NA #7 allegedly slapped the resident on the thigh. Neither NA intervened or reported the incident immediately, allowing both aides to continue working their shift, potentially putting other residents at risk. The facility's policy requires immediate reporting of any suspected abuse, neglect, or mistreatment, and mandates the removal of the accused staff member from resident care areas. However, NA #6 did not report the incident until several hours later, and NA #7 continued to work until she was removed from the floor by Nurse #7. The delay in reporting and failure to follow protocol highlights a significant lapse in the facility's abuse prevention and reporting procedures. Resident #3, who was not cognitively intact and had a history of being combative, was subjected to inappropriate handling by the staff. The incident was not addressed promptly, and the staff involved did not follow the established guidelines for managing combative behavior, such as walking away or seeking assistance. This deficiency in handling the situation and reporting it in a timely manner reflects a breach in the facility's duty to protect its residents from abuse and ensure their safety.
Failure to Transport Resident to Neurologist Appointment
Penalty
Summary
The facility failed to ensure that a resident with Parkinson's disease was transported to a scheduled neurologist appointment. The resident, who was admitted to the facility with a diagnosis of Parkinson's disease, was supposed to attend a neurologist appointment for medication adjustments and therapy recommendations. The family member of the resident had informed the facility of the appointment in advance, but two days before the appointment, the facility notified the family member that they could not provide transportation. This resulted in the appointment being rescheduled to a later date, causing a significant delay in the resident's care. The Transporter, who was responsible for the facility's transportation, realized a week before the appointment that she could not transport the resident due to a scheduling conflict. Attempts to arrange alternative transportation through a contracted company were unsuccessful as they were fully booked. The facility's Director of Nursing and Administrator acknowledged the transportation conflict and the failure to arrange alternative transportation, but the facility's physician believed the missed appointment did not impact the resident's care. Despite this, the family member was upset about the delay in the resident's neurologist visit.
Failure to Administer Prescribed Medication
Penalty
Summary
The facility failed to ensure that a resident with Parkinson's disease and a neurocognitive disorder with dementia received their prescribed medication, Carbidopa-Levodopa, as ordered by the physician. The resident was admitted with a physician's order for Carbidopa-Levodopa to be administered four times a day. However, on multiple occasions, the medication was not available for administration. On 11/10/2024, Nurse #7 discovered the medication was not available and notified the Director of Nursing and the pharmacy. Despite these efforts, the pharmacy indicated the medication would not be sent until a week later. The nurse documented the missed doses and informed the Physician's Assistant, but no hold order was given. Further issues occurred on 11/11/2024 and 11/20/2024, where the medication was again unavailable, and doses were missed. Nurse #6 documented that the medication was on hold, but no physician's order was found to support this action. Interviews with the Physician's Assistant and the Director of Nursing revealed a lack of communication and awareness regarding the unavailability of the medication. The Director of Nursing stated that the nursing staff should have ensured the medication was sent promptly and notified the provider, but this did not occur, leading to the deficiency.
Failure to Administer Essential Parkinson's Medication
Penalty
Summary
The facility failed to ensure that a resident with Parkinson's disease was free from significant medication errors. The resident was not administered six doses of Carbidopa-Levodopa, a medication critical for managing Parkinson's disease symptoms. The medication was ordered to be given four times a day, but due to unavailability, the doses were missed on multiple occasions. The issue began when a nurse discovered that the medication was not available and could not be obtained from the facility's electronic emergency medication system. Despite notifying the Director of Nursing and the pharmacy, the medication was not delivered promptly. The pharmacy indicated that a 'Refill Too Soon' form was needed before the medication could be sent. The nurse documented the unavailability of the medication and the ongoing efforts to resolve the issue, but the medication remained unavailable for several doses. Interviews with the nursing staff, Physician's Assistant, and the Director of Nursing revealed a lack of communication and documentation regarding the hold orders for the medication. The Physician's Assistant and the Director of Nursing were not aware of the missed doses, and there was no documented order to hold the medication. The Physician's Assistant acknowledged that the missed doses could have affected the resident's mobility, breathing, and swallowing, although no immediate harm was reported. The Director of Nursing stated that the nursing staff should have ensured the medication was available and notified the provider promptly.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 168 citations issued within 25 miles in the last 12 months — including the 4 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Salisbury
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Nc State Veterans Home - Salisbury | 0.1 mi | ★★★★★ | 12 | 1 |
| Compass Healthcare And Rehab Rowan, Llc | 1.3 mi | ★★★★★ | 2 | 0 |
| Piedmont Health & Rehab Center | 1.8 mi | ★★★★★ | 6 | 1 |
| Trinity Oaks | 2.4 mi | ★★★★★ | 0 | 0 |
| Salisbury Rehabilitation And Nursing Center | 3.2 mi | ★★★★★ | 17 | 1 |
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