Below average — CMS composite of the measures below.
A standard survey is most likely before around August 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 Autumn Care Of Waynesville during CMS and state inspections, most recent first.
A nurse failed to wear a gown while providing wound care to a resident with a chronic wound, despite the facility's Enhanced Barrier Precautions policy requiring both gloves and a gown for high-contact care activities. The nurse acknowledged forgetting to don the gown, and facility leadership confirmed she had received appropriate infection prevention training.
The facility failed to follow its abuse prevention and reporting policies in two cases involving residents with cognitive impairment. In one instance, a resident was struck by a staff member and the incident was not immediately reported, allowing the accused staff member to continue working. In another case, an abuse allegation reported to APS was not documented or communicated to the administrator or DON, and no internal investigation or required notifications were made.
A resident with advanced dementia was allowed to sign her own admission paperwork without the facility verifying or involving her designated legal representative, despite clear indications of cognitive impairment. The admission coordinator relied on the resident and her spouse's statements and did not obtain power of attorney documentation until discharge, resulting in the resident's legal representative not being included in the admission process.
A resident with severe cognitive impairment and dementia was physically struck on the arm by a nurse aide during care after becoming agitated and combative. The incident was witnessed by another aide, who delayed reporting the abuse due to fear of confrontation. The resident's care plan included interventions for managing agitation, but these were not followed, resulting in physical abuse that was not immediately reported or addressed.
A resident with severe cognitive impairment and on hospice care continued to receive PRN Lorazepam for anxiety and restlessness without a required 14-day stop date, despite repeated pharmacist recommendations. Nursing staff and the DON believed hospice residents were exempt from this requirement, resulting in the medication order remaining active for several months without the mandated stop date.
Four containers of expired fortified nutritional shake with nectar consistency were found stored in a nourishment room. The Dietary Manager, who inspects the nourishment rooms daily, was unaware of how the expired products were missed and suggested that newer staff may have stocked items incorrectly. The Administrator confirmed that expired products should be removed.
The facility failed to remove medication patches as ordered for two residents. One resident was found with two clonidine patches due to a missed removal, while another had a lidocaine patch left on overnight. The DON noted unclear orders may have contributed to the oversight.
The facility failed to ensure that a nurse and a paramedic completed their Skills Competency and required orientation before taking resident assignments independently. This led to a delayed medical response for a resident, who was later transferred to the hospital and subsequently passed away. The Director of Nursing and Staff Development Coordinator admitted to oversight in ensuring these competencies were completed.
Nursing staff failed to properly monitor and respond to changes in condition for diabetic residents, leading to critical health issues. One resident was not assessed in a timely manner and experienced a severe drop in blood sugar, while another resident's insulin was not administered as ordered, resulting in dangerously high blood sugar levels. Additionally, the facility did not assess a resident for significant weight gain and edema.
A resident experienced a medical emergency and was only responsive to painful stimuli, but EMS was not called until three hours later. The resident was diagnosed with metabolic encephalopathy due to a UTI and possibly cellulitis or hypoglycemia. The delay in initiating EMS and lack of ongoing assessment contributed to the resident's deteriorating condition and eventual death. The facility's staff failed to perform necessary assessments and timely communication with EMS.
A resident with a hinged knee brace developed a pressure injury that worsened due to inconsistent wound care and lack of initial padding on the brace. The facility staff failed to perform regular skin assessments and wound care as prescribed, leading to an infected wound with dead tissue. Key staff members were unaware of the injury, and there was no documentation of the brace being evaluated upon admission.
The facility failed to prevent injury during the transfer of a resident from a wheelchair to the bed, resulting in a laceration caused by a protruding screw. Additionally, the facility used an altered sit-to-stand lift for another resident, compromising safety and violating manufacturer instructions.
The facility failed to maintain clean and sanitary kitchen conditions, with observations of wet-nested and dirty dishware, debris on the kitchen floor, and dried food particles on various surfaces. The Dietary Manager attributed these issues to short staffing and rushing by the dietary staff.
A facility failed to accommodate a bariatric resident's transfer needs by not providing a suitable mechanical sit-to-stand lift. The resident experienced discomfort and pain due to an ill-fitting knee brace, and the use of pillows for padding compromised the lift's safety. Despite being aware of the issue, the facility did not take appropriate action to resolve it.
A resident with moderate cognitive impairment was moved to a new room without prior written notice, causing significant distress. Facility staff admitted to only providing verbal notifications, which contradicted the family's statements and violated the resident's rights.
The facility failed to accurately document the code status of a resident on the MOST form and did not provide EMS with a resident's advanced directive during an emergency transfer. These deficiencies involved incorrect documentation and missing DNR forms, leading to potential risks during emergency situations.
The facility failed to implement abuse and neglect policies by not submitting an Initial Allegation Report within two hours of being notified of neglect and allowing involved staff to continue working. Additionally, the facility did not report an allegation of staff-to-resident abuse immediately and failed to notify law enforcement.
The facility failed to maintain communication with the dialysis center, assess a resident post dialysis, and implement orders for fluid restrictions and a renal diet. The resident's care plan lacked necessary assessments, and the facility's staff were unaware of the resident's dietary and fluid restriction needs due to poor communication with the dialysis center.
The facility failed to maintain a medication error rate of less than 5%, resulting in an 8% error rate. A resident received an incorrect concentration and infusion rate of Meropenem, and the IV was not flushed as required. Nurse #11 was unaware of the need to flush the IV and assumed the premixed solution from the pharmacy was correct. The Pharmacy Consultant admitted an oversight, and the Medical Director confirmed the need for IV flushing.
A resident with severe cognitive impairment was found with unsecured medications at her bedside. The nurse responsible admitted to leaving the medications unattended, contrary to facility policy, which requires nurses to observe residents during medication administration.
The facility failed to initiate Enhanced Barrier Precautions (EBP) for a resident with a Permacath used for dialysis access. Observations and staff interviews revealed a lack of PPE and confusion about EBP requirements. The ADON and DON acknowledged the resident should have been on EBP, especially considering the need for assistance post-dialysis.
The facility failed to notify emergency contacts when a resident was sent to the ER and did not inform the provider of another resident's significant weight gain. The DON and Administrator confirmed that immediate notification protocols were not followed.
The Governing Body failed to have the Business Office Manager sign a Duty to Disclose Conflict of Interest form and approve or deny a plan to purchase property from a resident. The Business Office Manager facilitated the sale without disclosing the transaction to the Corporate Human Resources Representative or the Former Administrator, leading to a potential conflict of interest situation.
The facility failed to display survey results in a location accessible to residents during multiple observations. The survey results, previously kept in a blue notebook in the front lobby, were found in the receptionist's office due to an oversight.
The facility failed to provide a written notice of transfer/discharge to a resident and their representative and did not send a copy to the local Ombudsman. The resident was transferred to the hospital due to a change in condition, but the required notice was not completed by the nurse on duty. The Business Office Manager sent the notice the next business day but did not inform the Ombudsman.
Failure to Follow Enhanced Barrier Precautions During Wound Care
Penalty
Summary
Nurse #1 failed to follow the facility's Enhanced Barrier Precautions (EBP) policy during wound care for a resident with an unstageable pressure injury. According to the facility's policy, staff are required to don both gloves and a gown when performing high-contact care activities for high-risk residents, such as those with chronic wounds. During an observation, Nurse #1 entered the resident's room, performed hand hygiene, and wore gloves throughout the wound care process, but did not wear a gown at any point. The resident involved had a documented unstageable pressure injury and was considered high-risk under the facility's EBP policy. Nurse #1 acknowledged during an interview that she had received training on EBP and was aware of the requirement to wear a gown during wound care, but stated she forgot due to being nervous. The Director of Nursing and the Administrator confirmed that Nurse #1 had been trained and should have worn a gown during the procedure.
Failure to Implement Abuse Reporting and Protection Procedures
Penalty
Summary
The facility failed to follow and implement its abuse policy and procedures in two separate cases involving residents with cognitive impairments. In the first case, a resident with severe dementia was struck on the arm by a nursing assistant during care. Another nursing assistant witnessed the incident but did not immediately intervene or report the abuse to the on-duty nurse or administrator. Instead, the witness left the facility at the end of her shift and only reported the incident to the DON after arriving home. As a result, the accused staff member continued to work on the floor with access to other residents until the DON was notified and took action to remove her from the building. The incident was not reported immediately as required by facility policy, and the initial response was delayed. In the second case, an allegation of staff-to-resident abuse was reported to Adult Protective Services (APS) by a resident's roommate. The APS social worker visited the facility to investigate, but the facility's social worker and unit manager did not document or report the allegation to the administrator, state agency, or law enforcement as required. The administrator and DON were unaware of the allegation and the APS investigation until months later, when a letter from APS was found in the social worker's desk. There was no record of the incident in the facility's reportable incidents log, and the required internal investigation and notifications were not completed. Both cases demonstrate failures in immediate reporting, protection of residents, and adherence to established abuse policies. Staff did not follow procedures for timely intervention, reporting, and investigation, resulting in lapses in resident protection and regulatory compliance.
Failure to Verify Resident Representative for Cognitively Impaired Resident Admission
Penalty
Summary
The facility failed to determine whether a resident with advanced dementia had a designated Resident Representative before allowing the resident to sign admission paperwork. The resident, who had a diagnosis of advanced dementia as documented in a hospital discharge summary, was admitted to the facility and subsequently discharged to another skilled nursing facility. The resident's face sheet listed her as the primary contact for financial matters, with a family member as the emergency contact and another family member as the Resident Representative. Despite this, the admission paperwork was signed by the resident herself and witnessed by the former Admission Coordinator. Interviews revealed that the resident's family member, who was her legal representative, was not involved in the admission paperwork process and only became aware of the issue after the resident was transferred to another facility. The family member expressed concern that the resident, due to her dementia, would not have understood the documents she signed. The family member also noted that the resident's spouse, who was present during the signing, was overwhelmed and would not have understood the paperwork either. The family member stated she was available and could have signed the paperwork if contacted. The former Admission Coordinator acknowledged being aware of the resident's dementia diagnosis but stated she was not aware of its severity. She reported that both the resident and her spouse denied having a power of attorney at the time of admission. The Admission Coordinator allowed the resident to sign the paperwork based on her own assessment and the spouse's suggestion. It was only near the time of discharge that the facility received documentation of the legal representative's authority. Both the DON and the Administrator confirmed that the admission paperwork should have been signed by the resident's legal representative due to the resident's cognitive impairment.
Failure to Protect Resident from Physical Abuse by Staff
Penalty
Summary
A deficiency occurred when a severely cognitively impaired resident with dementia and hypertension was not protected from physical abuse by a staff member. During evening care, the resident became agitated and combative while being assisted by three nurse aides. According to direct observation by one nurse aide, another nurse aide struck the resident on the left lower arm with an open hand after the resident had hit her. The resident did not respond verbally or physically to being struck, and no injuries were observed during a subsequent assessment. The incident was witnessed by one nurse aide, who did not immediately report the abuse to the on-duty nurse due to fear of confrontation with the involved staff member. Instead, the witness left the facility at the end of her shift and reported the incident to the Director of Nursing after arriving home. Another nurse aide present in the room stated he did not observe the physical abuse but heard the involved aide express frustration toward the resident. The on-duty nurse and Director of Nursing were not made aware of the incident until after the witness had left the facility. The resident's care plan included specific interventions for managing cognitive loss and agitation, such as being patient, breaking tasks into subtasks, and gently redirecting inappropriate actions. Despite these interventions, the staff member's response to the resident's behavior resulted in physical abuse, which was not immediately reported or addressed by those present at the time.
Failure to Implement Required Stop Date for PRN Psychotropic Medication
Penalty
Summary
The facility failed to ensure that a PRN psychotropic medication, Lorazepam, prescribed for anxiety and restlessness, had a required 14-day stop date for a resident who was severely cognitively impaired and receiving hospice care. Despite multiple monthly drug regimen review consultation reports from the Consultant Pharmacist recommending discontinuation or the addition of a stop date, the Lorazepam order remained active without a stop date for several months. The physician initially accepted the pharmacist's recommendation but did not specify a stop date, and subsequent recommendations were either not implemented or declined with the rationale that the resident was on hospice care. Interviews with nursing staff and the DON revealed a misunderstanding among staff that hospice residents were exempt from the requirement for PRN psychotropic medication stop dates. The DON was unaware of this belief among staff and was not aware that the medication order lacked a stop date. The Administrator also believed hospice residents should continue their psychotropic medications but acknowledged awareness of the regulatory requirement for stop dates on PRN psychotropic medications.
Expired Nutritional Shakes Found in Nourishment Room
Penalty
Summary
Surveyors observed that four containers of fortified nutritional shake with nectar consistency, all past their use-by date, were found stored in one of the two nourishment rooms. The expired products were discovered during an inspection of the east side nourishment room. The Dietary Manager, when interviewed, stated she was unaware of how the expired containers were missed, despite conducting daily inspections of both nourishment rooms. She suggested that newer staff may have stocked the room incorrectly by placing newer products in front of older ones, which could have led to the expired items being overlooked. The Administrator confirmed awareness of the expired products and stated that all food products should be inspected and removed if expired.
Failure to Remove Medication Patches as Ordered
Penalty
Summary
The facility failed to properly manage the medication regimen for two residents, leading to the presence of unnecessary drugs. Resident #1, who was admitted with heart failure and high blood pressure, had an order for a clonidine patch to be applied once every seven days. However, on 08/25/24, Resident #1 was found with two clonidine patches with different application dates upon arrival at the emergency department. This occurred after Medication Aide #1 was unable to locate the previously applied patch on 08/21/24 and assumed it had fallen off, leading to the application of a new patch without removing the old one. Resident #2, admitted with lower back pain, had an order for a lidocaine patch to be applied daily and removed at bedtime. On 11/26/24, during a medication pass observation, Nurse #3 discovered that the previous day's patch had not been removed as ordered. Nurse #4, who was responsible for Resident #2's care on the evening of 11/25/24, was unaware of the removal order, indicating a lack of communication or clarity in the medication orders. The Director of Nursing acknowledged that the order for lidocaine patch removal was unclear, which may have contributed to the oversight. Both incidents highlight a failure to adhere to physician orders regarding medication administration, resulting in residents having unnecessary medications applied.
Failure to Complete Competency Checks and Orientation
Penalty
Summary
The facility failed to ensure that Nurse #1 and Paramedic #1 had completed their Skills Competency and required floor/unit orientation days with a preceptor before taking a resident assignment independently. Nurse #1 was informed by another nurse that Resident #280 had been excessively sleepy but failed to assess the resident until several hours later. When Nurse #1 finally assessed Resident #280, the resident was only responsive to painful stimuli. Despite being instructed to transfer the resident to the hospital, Nurse #1 did not notify Emergency Medical Services (EMS) and assumed that the oncoming staff member, Paramedic #1, would do so. Paramedic #1 also failed to assess the resident promptly and only called EMS hours later, resulting in a delayed transfer to the hospital where the resident later died. A review of Paramedic #1's job description and Orientation and Skills Competency Checklist revealed that several critical competencies were not completed, including knowledge of tube feeding, resident-centered care, and emergency procedures. The Director of Nursing (DON) had signed off on the checklist despite these gaps. Similarly, Nurse #1's Orientation and Skills Competency Checklist showed that she had not been checked off on essential skills such as Pharmacy Services, Emergency Medications, and Head to Toe Assessment. Both the Staff Development Coordinator (SDC) and the DON admitted to oversight in ensuring these competencies were completed. Resident #280 had a medical history that included a fracture, type 2 diabetes, atrial fibrillation, and heart disease. The resident's condition deteriorated due to the delayed medical response, leading to a hospital transfer where she was diagnosed with metabolic encephalopathy due to a urinary tract infection and possibly other conditions. The resident was later discharged to hospice and subsequently passed away. Interviews with facility staff, including the DON, SDC, and the Administrator, confirmed that the required competencies and orientation were not completed for Nurse #1 and Paramedic #1, leading to the deficient practice and the resident's adverse outcome.
Removal Plan
- Nurse #1 will complete the required days of floor/unit training with a preceptor prior to her next shift assigned to work.
- The Director of Nursing or Designee will sign off competencies for Nurse #1 on the Pharmacy Services, use of emergency medication back up kit, and or electronic medication dispenser (Omni Cell), Stat Meds, Diagnosis for Medication, Review of Required Assessments (paper or EHR), Head to Toe Assessment and Documentation, Device List, Vital Signs prior to next shift assigned to work.
- The Director of Nursing released Paramedic #1 before his notice expired.
- The Director of Nursing or Designee audited the employee files of licensed staff and Paramedics to ensure orientation and skills competency checklist were completed, any negative findings will be corrected immediately, and staff placed back into orientation or skills check off completed for any area missed during orientation.
- The Regional Director of Clinical Services educated the Director of Nursing, Assistant Director of Nursing, Administrator, Scheduler and Human Resources on the orientation process to include the required days of floor/unit training with a preceptor and completion of the skills competency checklist.
- The Director of Nursing or Designee will ensure all newly hired licensed staff have completed the required days of floor/unit training with a preceptor prior to being given an assignment.
- The Assistant Director of Nursing or Designee will complete the skill competency checklist for all newly hired licensed staff and Paramedics. The Director of Nursing or Designee will ensure all newly hired licensed staff and Paramedics have completed skills competency checklist prior to being given an assignment.
- Ad Hoc QAPI was completed related to following orientation policy and ensuring the skill checklist is completed for licensed staff and Paramedics prior to taking their first assignment.
Failure to Monitor and Respond to Diabetic Residents' Conditions
Penalty
Summary
Nursing staff failed to identify the seriousness of a change in condition for a resident with insulin-dependent diabetes and provide thorough ongoing monitoring and comprehensive assessments. On one occasion, a nurse reported that a resident was sleepy all day, but the resident was not assessed until several hours later, at which point she was only responsive to painful stimuli. The nurse did not check the resident's blood sugar and there was a significant delay in contacting Emergency Medical Services (EMS), resulting in the resident being transferred to the emergency room in an unresponsive state with a blood sugar level of 74 mg/dL. The resident was later diagnosed with metabolic encephalopathy and expired after being transferred to hospice care. Another resident with insulin-dependent diabetes was admitted to the facility, but the facility failed to administer sliding scale insulin as per the hospital discharge summary or monitor blood sugar levels according to physician orders. The resident reported extreme thirst and requested a blood sugar check, which revealed a dangerously high level of 548 mg/dL. This indicated a potential diabetic ketoacidosis, a life-threatening complication of diabetes. The facility's failure to monitor and administer insulin as ordered contributed to the resident's critical condition. Additionally, the facility failed to assess a resident for the cause of significant weight gain and edema. The deficient practices occurred for three sampled residents, highlighting a pattern of inadequate monitoring, assessment, and communication among nursing staff. These failures led to immediate jeopardy situations for the residents involved, necessitating corrective actions to address the deficiencies and prevent recurrence.
Removal Plan
- The Regional Director of Clinical Services educated Nurse #1 and Paramedic #1 on effective communication between staff during a Medical Emergency, timely assessment, monitoring, and assessment of change of condition including Blood Pressure, Pulse, Respirations, Temp, oxygen saturation and Blood Sugar if resident is a Diabetic.
- The Director of Nursing or Designee immediately audited the Situation, Background, Assessment and Recommendation and progress notes of residents sent to hospital to confirm that no delay in assessment, monitoring or transfer to hospital occurred. No negative findings were found.
- The Director of Nursing or Designee audited Nursing progress notes to ensure no change of conditions were found and not followed up on in a timely manner. No negative findings were found.
- The Social Worker/Administrator or Designee interviewed residents with a BIMS of 12 or above regarding if they have had a change of condition that was not followed up on immediately and if they felt they had a delay in treatment.
- The Director of Nursing or Designee audited Nursing progress notes of residents with a BIMS of less than 12 to ensure residents had no change of condition that was not followed up on immediately. No negative findings were noted.
- The Director of Nursing or Designee interviewed all nursing and therapy staff regarding knowledge of any residents having change of conditions that were not addressed. No negative findings were noted.
- The Director of Nursing or Designee educated all Certified Nursing Assistants on reporting any change of condition of residents to the nurse immediately. The Director of Nursing or Designee will ensure Certified Nursing Assistants that were not working will be educated prior to their next shift.
- The Director of Nursing or Designee educated Licensed Nurses and Paramedics on timely assessment and monitoring and assessment of change of condition including Blood Pressure, Pulse, Respirations, Temperature, Oxygen Saturation and Blood Sugar if resident is a Diabetic. The Licensed Nurses and Paramedics that were not working will be educated prior to their next shift. The Director of Nursing or Designee will ensure Licensed Nurses and Paramedics that were not working will be educated prior to their next shift.
- Director of Nursing or Designee educated all staff on effective communication between staff members during a Medical Emergency. The staff that were not working will be trained prior to their next shift. The Director of Nursing or Designee will ensure all staff that were not working will be educated prior to their next shift.
- The Director of Nursing or Designee educated all Licensed Nurses and Paramedics on observing and assessing residents for change of condition from baseline and communicating to provider for follow up and treatment in a timely manner. The Licensed Nurses and Paramedics that were not working will be educated prior to their next shift. The Director of Nursing or Designee will ensure Licensed Nurses and Paramedics that were not working will be educated prior to their next shift.
- The Director of Nursing or Designee educated all Licensed Nurses and Paramedics on recognizing serious decline of cognition and responsiveness of resident as an emergent occurrence and to contact provider and transfer to hospital immediately. The Director of Nursing or Designee will ensure Licensed Nurses and Paramedics that were not working will be educated prior to their next shift.
- Ad Hoc QAPI was completed regarding effective communication between staff in Medical Emergencies, timeliness of assessment, monitoring, and following provider orders to include transferring resident to hospital related to change of condition.
- The Regional Director of Clinical Services educated the Administrator, Director of Nursing, Assistant Director of Nursing, Scheduler and Human Resources on the orientation process that will include education on recognizing change of condition, effective communication during a Medical Emergency, timely assessment and monitoring, and assessment of change of condition including Blood Pressure, Pulse, Respirations, Temp, oxygen saturation, and Blood Sugar if resident is a Diabetic.
- The Director of Nursing or Designee will ensure newly hired Licensed Nurses or Paramedics receive education during Orientation on the Effective Communication during a Medical Emergency, timely assessment, monitoring, and assessment of change of condition including Blood Pressure, Pulse, Respirations, Temp, oxygen saturation and Blood Sugar if resident is a Diabetic.
- The Director of Nursing or Designee will ensure Agency Staff receive education on Effective Communication during a Medical Emergency, timely assessment, monitoring, and assessment of change of condition including Blood Pressure, Pulse, Respirations, Temp, oxygen saturation and Blood Sugar if resident is a Diabetic prior to first shift of working in facility.
Failure to Provide Timely Emergency Medical Services
Penalty
Summary
The facility failed to protect a resident's right to be free from neglect when a resident experienced a medical emergency and emergency medical services (EMS) were not promptly provided. The resident was only responsive to painful stimuli around 5:00 PM, but 911 was not initiated until 8:10 PM. The resident was transferred to the hospital and diagnosed with metabolic encephalopathy due to a urinary tract infection and possibly due to cellulitis/infected lower extremity wounds or hypoglycemia. The resident was later discharged to hospice care and subsequently expired. This incident occurred for one of three residents reviewed for neglect. The resident was admitted to the facility with diagnoses including a fracture of the right fibula, type 2 diabetes, atrial fibrillation, and heart disease. On the day of the incident, the resident was reported to be excessively sleepy, and by 5:00 PM, was only responsive to painful stimuli. Nurse #1, who was responsible for the resident, did not check the resident's blood sugar and only obtained vital signs once. Despite being advised by the on-call provider to send the resident to the emergency room at 6:30 PM, Nurse #1 did not call EMS and left the facility, assuming that Paramedic #1 would handle it. Paramedic #1, who took over the shift, also failed to call EMS immediately and only did so at 8:10 PM after realizing that EMS had not been contacted. The delay in initiating EMS and the lack of ongoing assessment and monitoring contributed to the resident's deteriorating condition. The resident was found to be unresponsive and hypoglycemic by EMS and was transferred to the hospital, where she was diagnosed with metabolic encephalopathy. The facility's Director of Nursing and Administrator acknowledged the errors made by Nurse #1 and Paramedic #1, including the failure to perform head-to-toe assessments, ongoing vital signs, and timely communication with EMS. The incident highlighted significant lapses in the facility's emergency response and monitoring protocols, leading to the resident's decline and eventual death.
Removal Plan
- The Regional Director of Clinical Services educated Nurse #1 and Paramedic #1 on effective communication between staff during a Medical Emergency, timely assessment and monitoring and assessment of change of condition including Blood Pressure, Pulse, Respirations, Temp, oxygen saturation and Blood Sugar if resident is a Diabetic.
- The Director of Nursing or Designee immediately audited the Situation, Background, Assessment and Recommendation and progress notes of residents sent to hospital to confirm that no delay in assessment, monitoring or transfer to hospital occurred. No negative findings were found.
- The Director of Nursing or Designee audited Nursing progress notes to ensure no change of conditions were found and not followed up on in a timely manner. No negative findings were found.
- The Social Worker/Administrator or Designee interviewed residents with a BIMS of 12 or above regarding if they have had a change of condition that was not followed up on immediately, if they had any concerns of neglect and if they felt they had a delay in treatment. No negative findings were noted.
- The Director of Nursing or Designee audited Nursing progress notes of residents with a BIMS of less than 12 to ensure residents had no change of condition that was not followed up on immediately. No negative findings were noted.
- The Director of Nursing or Designee interviewed all nursing and therapy staff regarding knowledge of any residents having change of conditions that were not addressed and if they were aware of any resident neglect. No negative findings were noted.
- The Director of Nursing or Designee educated all staff on reporting any change of condition to the nurse immediately. The Staff that were not working will be educated prior to start of their next shift.
- The Director of Nursing or Designee educated all staff on effective communication between staff members during a Medical Emergency. The Staff that were not working will be educated prior to start of their next shift.
- The Director of Nursing or Designee educated all Licensed Nurses and Paramedics on observing and assessing residents for change of condition from baseline and communicating to provider for follow up and treatment in a timely manner. The Licensed Nurses and Paramedics that were not working will be educated prior to the start of their next shift.
- The Director of Nursing or Designee educated all Licensed Nurses and Paramedics on recognizing serious decline of cognition and responsiveness of resident as an emergent occurrence and to contact provider and transfer to hospital immediately. The Licensed Nurses and Paramedics that were not working will be educated prior to the start of their next shift.
- The Director of Nursing or Designee educated Licensed Nurses and Paramedics on timely assessment and monitoring and assessment of change of condition including Blood Pressure, Pulse, Respirations, Temp, oxygen saturation and Blood Sugar if resident is a Diabetic and the Abuse and Neglect Policy. The Licensed Nurses and Paramedics that were not working will be educated prior to the start of their next shift.
- The Director of Nursing or Designee educated all staff on the Abuse and Neglect Policy. The Staff that were not working will be educated prior to start of their next shift.
- Ad Hoc QAPI was completed regarding Abuse and Neglect. In addition, effective communication between staff in Medical Emergencies, timeliness of assessment and monitoring of change of conditions to include transferring resident to hospital.
- The Regional Director of Clinical Services educated the Administrator, Director of Nursing, Assistant Director of Nursing, Scheduler and Human Resources on the Orientation Process that will include education on recognizing change of condition, effective communication during a Medical Emergency, timely assessment and monitoring and assessment of change of condition including Blood Pressure, Pulse, Respirations, Temp, oxygen saturation and Blood Sugar if resident is a Diabetic.
- The Director of Nursing or Designee will ensure newly hired Licensed Nurses or Paramedics receive education on the Effective Communication during a Medical Emergency, Abuse and Neglect Policy and timely assessment and monitoring and assessment of change of condition including Blood Pressure, Pulse, Respirations, Temp, oxygen saturation and Blood Sugar if resident is a Diabetic in Orientation.
- The Director of Nursing or Designee will ensure Agency Staff receive education on Effective Communication during a Medical Emergency, the Abuse and Neglect Policy and timely assessment and monitoring and assessment of change of condition including Blood Pressure, Pulse, Respirations, Temp, oxygen saturation and Blood Sugar if resident is a Diabetic prior to first shift of working in facility.
Failure to Prevent Pressure Injury from Hinged Knee Brace
Penalty
Summary
The facility failed to prevent a pressure injury for a resident wearing a hinged knee brace. The resident, who had a right proximal tibia fracture and required a hinged knee brace, developed an open pressure injury that became infected. The care plan included skin checks and monitoring for changes, but no skin assessments were completed for the right lower extremity initially. The wound was first documented on 1/30/2024, and wound care orders were given, but there were multiple instances where wound care was not documented as performed according to the prescribed schedule. The wound worsened over time, increasing in size and developing dead tissue. Despite the worsening condition, wound care documentation was inconsistent, with several dates missing. The resident's wound care was not consistently performed, and the knee brace was not padded initially, which contributed to the development and worsening of the wound. The Physical Therapy Director was asked to pad the brace only after the wound was identified, and there was no documentation that the brace was evaluated upon the resident's admission. Interviews with staff revealed a lack of awareness and communication regarding the resident's condition. The Paramedic who acted as the Wound Care Nurse did not consistently perform wound care, and the Director of Nursing and Administrator were unaware of the pressure injury. The Physical Therapy Director confirmed that Occupational Therapy should have evaluated the brace upon admission, but no documentation was provided to support that this was done.
Failure to Ensure Safe Transfers for Residents
Penalty
Summary
The facility failed to prevent injury during the transfer of Resident #280 from a wheelchair to the bed, resulting in a laceration to the resident's left lower leg. The incident occurred when two Physical Therapy Assistants (PTAs) were assisting the resident, and a screw protruding from the wheelchair leg caused the injury. Despite the presence of the family member who witnessed the screw, the wheelchair was not taken out of service immediately, and the PTAs did not acknowledge the screw as the cause of the injury. The resident required emergency medical treatment, including sutures for the laceration, and the wheelchair was only padded after the incident occurred. In another incident, the facility failed to provide a safe transfer for Resident #60 by using a sit-to-stand lift that was not suitable for the resident's size. The resident's legs did not fit into the knee brace molds of the lift, and pillows were used to pad the knee brace, which altered the lift and compromised its safety. Despite the Director of Rehabilitation and the Administrator being aware of the issue, the lift was used with the modifications, and the leg safety straps could not be fastened correctly. This practice was against the manufacturer's instructions and posed a risk of injury to the resident. Interviews with staff, including the Director of Nursing (DON) and the Quality Assurance (QA) nurse, revealed that the use of pillows to pad the knee brace was not authorized and was considered unsafe. The sit-to-stand lift company representative confirmed that any modifications, such as adding pillows, would jeopardize the safety of the lift. Despite these concerns, the facility continued to use the altered lift for Resident #60, leading to a deficiency in providing adequate supervision and safe transfer practices.
Failure to Maintain Sanitary Kitchen Conditions
Penalty
Summary
The facility failed to maintain clean and sanitary kitchen conditions, as evidenced by debris on the kitchen floor and in the tile grout, dried food particles on a utility cart used to store clean dishware, and dried debris on the steam table hood and outside oven surfaces. Additionally, the facility did not ensure that ready-for-use metal pans, insulated dome plate covers, insulated plate under liners, and dishware were clean and not stacked wet. These issues were observed during two separate kitchen inspections, indicating a pattern of non-compliance with professional standards for food storage, preparation, and service. During an initial tour of the kitchen, it was observed that dishware ready for use was stacked wet and dirty. Specific instances included wet-nested divided plates, insulated plate under liner bottoms, and metal pans. Dirty dishware with yellow, black, brown, and white particles was also noted. The utility cart used to store clean dishes was found to be dirty with loose and dried food particles. The kitchen floors had loose trash and food debris, and the oven and steam table hood had dried food particles and crusted debris. The Dietary Manager (DM) acknowledged these issues, attributing them to short staffing and rushing by the dietary staff. A follow-up observation revealed continued issues with wet-nested and dirty dishware. Despite the DM's education of dietary staff on proper procedures, the problems persisted. Interviews with the DM and a Dietary Aide confirmed the process for cleaning and inspecting dishes, but the staff failed to ensure that dishes were clean and dry before stacking them. The Administrator expressed surprise at the findings and attributed the issues to the kitchen being shorthanded and rushing to complete tasks.
Failure to Accommodate Bariatric Resident's Transfer Needs
Penalty
Summary
The facility failed to accommodate the needs of a bariatric resident who required a mechanical sit-to-stand lift with a larger knee brace for transfers. The resident, who weighed 340.8 lbs and had a history of morbid obesity and nontraumatic intracranial hemorrhage, experienced discomfort and pain during transfers due to the ill-fitting knee brace molds on the sit-to-stand lift. Despite the resident's complaints and the addition of pillows for padding, the discomfort persisted, and the safety of the lift was compromised as the leg safety straps could not be fastened correctly with the added pillows. Interviews with various staff members, including the Director of Rehabilitation, the Maintenance Director, the Quality Assurance nurse, and the Director of Nursing, revealed that the facility was aware of the issue but did not take appropriate action to resolve it. The Maintenance Director had contacted the lift supply company, which did not rent bariatric lifts but sold them. However, no further efforts were made to find a suitable lift from other retailers. The Director of Nursing and the Quality Assurance nurse both acknowledged that using pillows to pad the knee brace was unsafe and altered the lift, yet the practice continued. The Administrator was aware of the resident's discomfort and the need for a bariatric sit-to-stand lift but relied on the Rehabilitation Director's recommendation to use pillows for padding. The lift company representative confirmed that the facility's sit-to-stand lift had an older knee brace model and recommended against using pillows, as it jeopardized the safety of the lift. The failure to provide a suitable lift and the continued use of an altered lift led to the deficiency in accommodating the resident's needs.
Failure to Provide Written Notice of Room Change
Penalty
Summary
The facility failed to provide Resident #230 with a written notice of a room change, including the reason for the change. Resident #230, who was moderately cognitively impaired and had diagnoses including acute gastric ulcer with perforation, major depressive disorder, and hypertension, was moved from one room to another without prior written notification. The resident was informed verbally by an unknown staff member on the morning of the move, which caused significant distress. The resident's family members were also not properly notified, either verbally or in writing, about the room change. Interviews with facility staff, including the Social Worker, Admissions Director, and Director of Nursing, revealed that the facility's practice was to provide verbal notifications only and that written notices were not given for internal room changes. The Social Worker claimed to have verbally informed a family member, but this was contradicted by the family member's statement. The Admissions Director also stated that a progress note was written for each room change, but no written documentation of the notice was found in the electronic health record. This lack of proper notification violated the resident's right to receive written notice before a room change.
Failure to Accurately Document and Provide Advanced Directives
Penalty
Summary
The facility failed to accurately document the code status of Resident #12 on the Medical Orders for Scope of Treatment (MOST) form. Despite having a Do Not Resuscitate (DNR) order dated 10/6/2023 and a care plan indicating no chest compressions, the MOST form dated 1/24/2024 incorrectly indicated that Resident #12 was a full code. This discrepancy was confirmed by the Social Worker (SW), who admitted to making a mistake on the form. The Nurse Practitioner (NP) and Director of Nursing (DON) were unaware of the inconsistency, and the SW did not document any education provided to the resident or family regarding advanced directives in the medical record. For Resident #280, the facility failed to provide Emergency Medical Services (EMS) with a copy of the resident's advanced directive when she was transferred to the emergency room after being found unresponsive. Despite having a DNR order dated 1/11/2024, the EMS assessment documented that no advanced directives were provided, and the DNR form could not be found. Interviews with the paramedic, SW, Medical Records Coordinator, and QA Nurse revealed that the DNR form was not scanned into the Electronic Health Record (EHR) and was not in the advanced directive book at the nurse's station. The DON was also unaware that the DNR form was missing during the transfer. These deficiencies highlight a lack of proper documentation and communication regarding residents' advanced directives. The facility's staff, including the SW, NP, DON, and Medical Records Coordinator, failed to ensure that the residents' code status and advanced directives were accurately documented and readily available, leading to potential risks during emergency situations.
Failure to Implement Abuse and Neglect Policies
Penalty
Summary
The facility failed to implement their abuse policies and procedures by not submitting an Initial Allegation Report within two hours of being notified of resident neglect. On 4/30/2024 at 6:10 PM, the facility was informed of neglect involving a resident who was only responsive to painful stimuli. Nurse #1 did not initiate Emergency Medical Services (EMS) or perform necessary assessments and monitoring. Paramedic #1, who took over the shift, also failed to perform required assessments and did not notify EMS until 8:10 PM. Despite being aware of the neglect, the facility allowed both Nurse #1 and Paramedic #1 to continue working, placing residents at further risk. The required Initial Investigation Report was not completed promptly, and the facility did not list the accused employees in the report. The Administrator and Regional Nurse Consultant admitted to not following the mandatory two-hour reporting requirement and failing to suspend the involved staff immediately. In another incident, the facility failed to report an allegation of staff-to-resident abuse to administration immediately and did not notify law enforcement. On 1/26/2024, a resident wheeled herself into the nursing station and refused to leave when instructed by Nurse #14. The nurse forcibly removed the resident, leading to a physical altercation. The incident was reported to the Director of Nursing (DON) two days later, who then contacted the administrator. The facility did not notify law enforcement, believing a crime had not been committed. Nurse #14 was terminated during the investigation, but the delay in reporting and failure to notify law enforcement were significant lapses in protocol. These deficiencies highlight the facility's failure to adhere to its abuse and neglect policies, including timely reporting to the Department of Health and law enforcement, and taking immediate steps to protect residents. The lapses in communication and procedural adherence placed residents at risk and demonstrated a lack of proper oversight and response to serious allegations of neglect and abuse.
Failure to Maintain Communication and Implement Dialysis Orders
Penalty
Summary
The facility failed to maintain ongoing communication with the dialysis center, assess a resident post dialysis, and implement orders from the dialysis center for fluid restrictions and a renal diet for a resident with end-stage renal disease. The resident's care plan included hemodialysis care and nutrition interventions, but it did not include assessing the dialysis access site, obtaining weight, or vital signs post dialysis. The resident's electronic medical record (EMR) lacked documentation of post dialysis nursing notes, vital signs, and weights for several dates in March and April 2024. Interviews with facility staff revealed that there was supposed to be a communication folder sent back and forth between the facility and the dialysis center, but this was not consistently done. The dialysis center nurse confirmed that the resident had orders for a renal diet and fluid restrictions, which were not communicated to or implemented by the facility. The facility's registered dietician (RD) had not communicated with the dialysis center RD for six months and was unaware of the resident's need for a renal diet and fluid restrictions. The facility's nurses and director of nursing (DON) acknowledged the lack of communication and documentation regarding the resident's dialysis care. The medical director and administrator also confirmed the absence of communication from the dialysis center about the resident's dietary and fluid restriction needs. The facility did not receive routine notes or lab results from the dialysis center unless specifically requested, and there was no special monitoring for the resident when she refused to go to dialysis.
Medication Error Rate Exceeds 5%
Penalty
Summary
The facility failed to maintain a medication error rate of less than 5%, resulting in an 8% error rate. This was observed during a medication pass for a resident with diagnoses including diabetes, genitourinary conditions, and a UTI. The resident had a physician's order for Meropenem 1 gram IV to be infused every 8 hours, mixed with 100 mL of 0.9% Normal Saline, and to be infused over 3 hours. However, Nurse #11 administered the medication using a premixed solution from the pharmacy that contained only 50 mL of Normal Saline and programmed the infusion rate incorrectly. Additionally, Nurse #11 failed to flush the IV before administering the medication, as required by the physician's order. Interviews with Nurse #11, the Pharmacy Consultant, the Medical Director, and the Director of Nursing revealed that Nurse #11 was unaware of the need to flush the IV and had assumed the premixed solution from the pharmacy was correct. The Pharmacy Consultant admitted that the pharmacy should have advised the facility to change the order and infusion rate. The Medical Director confirmed that the dose and rate administered would not have been harmful but acknowledged the need for IV flushing. The Director of Nursing reported that Nurse #11 had self-reported the medication errors. These actions and inactions led to the facility's failure to maintain the required medication error rate, affecting the resident's care.
Failure to Secure Medications at Bedside
Penalty
Summary
The facility failed to secure medications found at the bedside for one resident. Resident #53, who was admitted with diagnoses including unspecified dementia, hypertension, and anxiety, was observed with a cup of medications on her bedside table. The resident, who was severely cognitively impaired according to a recent MDS assessment, was unaware of the medications or the need to take them. Nurse #8, responsible for administering medications on the 500 hall, admitted to leaving the medications unattended. The Director of Nursing confirmed that it was against facility policy to leave medications at the bedside and that nurses are expected to observe residents while administering medications.
Failure to Implement Enhanced Barrier Precautions for Resident with Indwelling Device
Penalty
Summary
The facility failed to initiate Enhanced Barrier Precautions (EBP) for a resident with an indwelling vascular access device, specifically a Permacath used for dialysis access. Observations revealed that there was no personal protective equipment (PPE) located outside or inside the resident's room, and staff interviews indicated a lack of clarity and consistency regarding the use of EBP for residents with indwelling devices. The facility's policy required EBP for high-contact care activities for residents with chronic wounds and indwelling devices, but this was not implemented for the resident in question. Interviews with nursing staff and nursing assistants revealed confusion about the necessity of EBP for the resident with the Permacath. Nurse #2 and NA #3 both indicated that they were unsure or had been misinformed about the requirements for EBP, believing it was only necessary for residents with catheters and wounds. The Assistant Director of Nursing (ADON) and Director of Nursing (DON) also acknowledged that the resident should have been on EBP, especially considering the resident's need for assistance with activities of daily living (ADLs) after returning from dialysis. The Medical Director and the facility Administrator confirmed that residents with indwelling devices should be on EBP. The ADON admitted that she had not considered the resident's increased need for assistance post-dialysis when deciding against EBP. The DON also recognized that the resident should have been on EBP if staff had to reinforce the dressing or assist with care when the resident was weak after dialysis. The lack of EBP implementation for the resident with the Permacath represents a failure to adhere to the facility's infection prevention and control program.
Failure to Notify Emergency Contacts and Provider of Significant Changes
Penalty
Summary
The facility failed to notify the emergency contacts when a resident had a change in condition and was sent to the emergency room. Resident #280 was found lethargic and barely arousable, prompting Nurse #1 to contact the on-call physician, who advised sending the resident to the hospital. However, Nurse #1 did not notify the resident's representative of the change in condition or the transfer. Paramedic #1 attempted to call the first emergency contact but only left a generic voicemail and did not make further attempts to contact other emergency contacts. The resident's representative was not aware of the transfer until the hospital ICU nurse called the next day. Both the DON and the Administrator confirmed that the family should have been notified immediately and that multiple attempts should have been made to reach emergency contacts if the first contact was unreachable. The facility also failed to notify the provider of a significant weight gain for another resident, Resident #18, who required diuretic medication. Resident #18 experienced a 7.38% weight gain over a 30-day period, but there was no documentation that the provider had been notified. The QA nurse admitted to not specifically reviewing the weights with the NP or MD and did not remember notifying them of the significant weight gain. The Medical Director and NP were unaware of the weight gain until much later, and both stated that the provider should have been notified sooner. The DON confirmed that the weight gain should have been discussed in clinical meetings and conveyed to the NP/MD promptly. Both deficiencies highlight a failure in communication and notification protocols within the facility. In the case of Resident #280, the lack of immediate notification to the family and multiple emergency contacts was evident. For Resident #18, the significant weight gain and associated health risks were not promptly communicated to the provider, delaying necessary medical intervention. These lapses in protocol were acknowledged by the facility's staff, including the DON and the Administrator.
Failure to Disclose Conflict of Interest in Property Purchase
Penalty
Summary
The Governing Body or its designated person failed to have the Business Office Manager sign a Duty to Disclose Conflict of Interest form and approve or deny a plan to purchase property from a resident. The facility's Ethical Business Practices and Conflicts of Interest policy requires employees to disclose any financial interest or relationship with residents, vendors, or competitors. However, the Business Office Manager did not disclose her interest in purchasing property from a resident, leading to a potential conflict of interest situation. Resident #8, who was cognitively intact and had no exhibited behaviors, sold a double wide, an old house, and a portion of land to the Business Office Manager in May 2023. The resident did not have an advocate during the process and could not recall the sale amount. The Business Office Manager facilitated the sale quickly, involving her spouse and an attorney, without disclosing the transaction to the Corporate Human Resources Representative or the Former Administrator, as required by the facility's policy. Interviews with various staff members, including the Former Nurse Aide, Former Administrator, and Current Administrator, revealed that the Business Office Manager did not follow the facility's conflict of interest policy. The Corporate Human Resources Official confirmed that the Business Office Manager had not submitted any conflict-of-interest documentation and was unaware of the property purchase. The Register of Deeds verified the property transfer to the Business Office Manager and her spouse, further confirming the deficiency in policy implementation.
Failure to Display Survey Results in Accessible Location
Penalty
Summary
The facility failed to display survey results in a location accessible to residents during five observations. During a tour of the facility, the survey results were not observed in the common areas, including the front lobby where a small table under a television screen was empty. Subsequent tours confirmed the absence of survey results in accessible locations. During a Resident Council group meeting, residents indicated that the survey results used to be in a blue notebook in the front lobby. An interview with the DON revealed that the blue notebook was intended to be in the lobby. However, an observation and interview with the Administrator revealed that the survey results were found on a bookshelf in the receptionist's office, which had been moved from the front lobby, and this was an oversight.
Failure to Provide Timely Transfer/Discharge Notice
Penalty
Summary
The facility failed to provide a written notice of transfer/discharge to the resident and resident representative and did not send a copy of the notice to the local Ombudsman for one resident reviewed for discharge. Resident #280, who was cognitively intact, was transferred to the hospital due to a change in condition. The nurse on duty did not complete the required notice of transfer/discharge form and was not familiar with the form. The Business Office Manager completed the form the next business day and sent it via certified mail to the resident's home address but did not send a copy to the Ombudsman, as she was unaware of this requirement. Interviews with staff, including the paramedic, nurse, Business Office Manager, Director of Nursing, and Administrator, revealed a lack of understanding and communication regarding the proper procedure for completing and distributing the notice of transfer/discharge form. The Ombudsman confirmed that she had not received any transfer/discharge notices from the facility since January 2024. The Resident Representative received the notice of transfer/discharge on 3/26/2024, significantly later than the transfer date.
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Illustrative
What surveyors actually found near you
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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.
Illustrative
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Nursing homes near Waynesville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Skyland Terrace And Rehabilitation | 2.9 mi | ★★★★★ | 3 | 0 |
| Maggie Valley Health And Rehabilitation Center | 6.3 mi | ★★★★★ | 4 | 0 |
| Smoky Mountain Health And Rehabilitation Center | 6.4 mi | ★★★★★ | 3 | 0 |
| Silver Bluff | 7.6 mi | ★★★★★ | 14 | 0 |
| Vero Health & Rehab Of Sylva | 12.6 mi | ★★★★★ | 7 | 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 July 2026) and official state health department websites.