Below average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Ayden Court Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
The facility failed to designate a qualified Infection Preventionist responsible for the infection prevention and control program. The DON stated the IP position was vacant and that she and the ADON were sharing the duties, but she could not provide documentation showing that either had completed the required specialized training. She also believed the SDC may have completed SPICE, but documentation could not be obtained.
A resident with Alzheimer's disease was ordered Olanzapine as PRN for nighttime agitation and increased fall risk, but the MAR showed it was given nightly instead. The resident was coded as cognitively intact, and staff interviews found no documented agitation, behaviors, or falls after admission, while the NP and Medical Director acknowledged the order should have reflected PRN use.
A resident with unspecified Alzheimer's disease had an admission MDS that was coded incorrectly for antipsychotic medication review. The resident had an order for Olanzapine 2.5 mg at bedtime, and the MAR showed the medication was given for several days after admission, but the MDS section was marked as not receiving antipsychotic medication since admission. The MDS Coordinator, Facility Nurse Consultant, and DON acknowledged the assessment should have reflected the antipsychotic use.
Pharmacy review failed to identify medication irregularities for a resident receiving olanzapine. The resident had Alzheimer’s disease and no mental health dx, yet the antipsychotic order was documented inconsistently as scheduled vs PRN, and the pharmacist did not question the lack of a clear supporting dx or clarify the order with the NP. The NP and Medical Director both stated the order should have been PRN and that the pharmacy consultant should have identified the irregularity.
Failure to use required PPE during tracheostomy care: A resident with a tracheostomy was on EBP, with signage and PPE available outside the room. During observed trach care, an RN performed hand hygiene and wore gloves but did not don a gown as required by the facility’s infection control policy for high-contact care activities. The RN acknowledged awareness of the EBP status, and the DON and ADON stated the gown and gloves should have been worn.
A resident with respiratory failure, tracheostomy, and a Passy-Muir speaking valve, who was a full code, was found unresponsive and not breathing by CNAs. The assigned RN briefly assessed the resident, left to verify code status and call a Code Blue, and then initiated CPR with staff using a backboard and AED. During the code, staff provided ventilations with a bag-valve mask over the resident’s mouth and nose, did not remove the Passy-Muir Valve, and did not assess or suction the tracheostomy, contrary to the facility’s trach/CPR policy and the valve manufacturer’s instructions. When EMS arrived, they removed the Passy-Muir Valve, found it and the trach tube filled with secretions and a mucus plug, performed deep suctioning, and then ventilated via the tracheostomy, ultimately obtaining a pulse before transporting the resident to the hospital, where she was later pronounced deceased.
The facility failed to accurately complete MDS assessments for two residents, leading to deficiencies in coding cognition, mood, and discharge destination. One resident's cognition and mood assessments were incomplete due to staff unawareness of requirements, while another resident's discharge destination was incorrectly coded. The facility's staff acknowledged these errors.
A resident with hemiplegia and contracture in the left hand did not consistently have a prescribed palm guard applied, as observed during a survey. Despite instructions from physical therapy, the palm guard was often found in a basket rather than in the resident's hand. Staff interviews revealed that the resident was sometimes resistive to care, but there was no documentation of refusals. The DON was unaware of the issue, indicating a lapse in communication and documentation.
A facility failed to maintain a clean and homelike environment in a resident's room, as observed by a family member and staff. The ceiling vent was in disrepair, with a black substance and signs of water damage. The Maintenance Director admitted the issue was overlooked, and no work order was found for the vent. The Administrator expected maintenance staff to inspect and repair as needed.
A resident's medications, including Oxycodone, were mishandled in an LTC facility, leading to the misappropriation of a card containing 30 tablets. The Unit Manager and ADON failed to ensure the medications were returned to the pharmacy as required, and the control bag number on the Return of Drug form was altered. The discrepancy was discovered when the medications were found in the cart, but the DON was not immediately notified. The facility's policy for returning controlled substances was not followed.
A resident with chronic osteomyelitis was prescribed Oxycodone HCL 10 mg every 4 hours but received only 5 mg on two occasions due to confusion by medication aides. The facility's records showed inconsistencies, and the DON and Administrator expected correct dosages to be administered.
A facility failed to post cautionary signage outside a resident's room to indicate the use of supplemental oxygen. The resident, who had acute respiratory failure and COPD, was observed using a nasal cannula for oxygen, but no signage was present. Staff interviews confirmed that signage should have been placed upon admission or change in condition, highlighting a lapse in protocol.
A medication cart at an LTC facility was found unlocked and unattended in the hallway, contrary to protocol. Nurse #7 admitted to leaving it unlocked and later secured it upon noticing a surveyor. The DON confirmed that medication carts should always be locked when unattended.
A resident with osteomyelitis of the vertebra had discrepancies in their medical records regarding Oxycodone HCL administration. The narcotic count record showed 5 mg doses were signed out, while the MAR documented 10 mg doses. Staff interviews revealed inconsistencies, with one medication aide confirming a 5 mg administration, contrary to the MAR. The DON and Administrator expected accurate medical records, indicating a failure in maintaining them.
Failure to Designate a Qualified Infection Preventionist
Penalty
Summary
The facility failed to designate a qualified Infection Preventionist responsible for the Infection Prevention and Control Program. During an interview on 5/5/2026, the DON stated that the Infection Preventionist position was vacant and that she and the ADON were sharing the responsibilities. She said both had completed infection prevention programs out of state and that she would try to retrieve documentation. The DON could not recall the name of the infection prevention and control program she completed in Ohio, but said it was similar to the SPICE program offered in North Carolina. On 5/6/2026, the DON stated she had been unable to locate documentation for herself or the ADON, but believed the SDC had completed SPICE and would obtain that documentation. In a later interview the same day, the DON stated she was unable to obtain documentation showing that there was a qualified Infection Preventionist at the facility. The Administrator was not available for interview during the survey.
Antipsychotic Given Daily Without Documented PRN Need
Penalty
Summary
The facility failed to ensure a resident had an indication and diagnosis for the use of an antipsychotic medication and failed to administer the medication on an as-needed basis as specified in the hospital discharge summary. Resident #32 was admitted with diagnoses including Alzheimer's disease, chronic pain, hyperlipidemia, and cervical radiculopathy. The hospital discharge summary ordered Olanzapine 2.5 mg at bedtime as needed if agitated at night causing increased fall risk, and the resident's EMR included a signed informed consent for antipsychotic use. The admission MDS coded the resident as cognitively intact and as receiving antipsychotic medication. The facility's physician order entered on 4/9/26 listed Olanzapine 2.5 mg at bedtime for agitation at night causing increased fall risk, and the MAR showed the medication was administered nightly from 4/9/26 through 5/7/26. The care plan addressed psychotropic drugs and included monitoring effectiveness and side effects, but the record and staff interviews did not document agitation, behaviors, or falls after admission. The NP stated the medication should have been administered on a PRN basis for agitation, while the Medical Director stated the order should have been entered correctly to reflect PRN use; both also stated they had no concern about the resident receiving the medication daily despite no documented agitation, behaviors, or falls in the facility.
Inaccurate MDS Coding for Antipsychotic Medication Review
Penalty
Summary
The facility failed to accurately code a Minimum Data Set (MDS) assessment for antipsychotic medication review for one resident with unspecified Alzheimer's disease. The resident was admitted with a physician order for Olanzapine 2.5 mg at bedtime, and the April 2026 MAR showed the medication was administered from 4/9/26 through 4/15/26. However, the admission MDS dated [DATE] indicated the resident received antipsychotic medications, while the Antipsychotic Medication Review section was coded as not receiving antipsychotic medication since admission. During interview, the MDS Coordinator stated she completed that section and should have indicated the resident had received antipsychotic medications since admission, and she verified the assessment was inaccurate. The Facility Nurse Consultant and DON also stated the resident's MDS assessments should have been coded accurately to reflect antipsychotic use since admission.
Pharmacy Review Failed to Identify Antipsychotic Order Irregularity
Penalty
Summary
The licensed pharmacist failed to complete and document a monthly drug regimen review that identified medication irregularities for a resident receiving olanzapine. Resident #32 was admitted with Alzheimer’s disease and no mental health diagnoses, yet the hospital discharge summary and facility orders reflected olanzapine use for agitation/fall risk. The admission MRR on 4/10/26 noted the resident was on olanzapine and recommended a DISCUS evaluation, but no other concerns were identified. A DISCUS evaluation was completed on 4/13/26 with no concerns noted. A later MRR on 5/6/26 again found no drug irregularities and made no recommendations regarding the olanzapine. During interview, the pharmacy consultant stated he could not locate a supporting diagnosis in the electronic record at the time of review, but relied on the hospital discharge summary describing worsening mentation, agitation, decline in functioning, and recurrent falls to support continued use of the antipsychotic. He also stated he was unsure whether the olanzapine order was intended as scheduled or PRN and said he should have clarified it with the NP. The NP stated the medication should have been administered PRN as ordered from the hospital physician, and the Medical Director stated the order should have been entered correctly as PRN and the pharmacy consultant should have questioned the irregularity.
Failure to Use Required PPE During Tracheostomy Care
Penalty
Summary
The facility failed to implement infection prevention and control practices when a nurse provided tracheostomy care to a resident on Enhanced Barrier Precautions without wearing a gown. The facility’s Infection Control Manual stated that Enhanced Barrier Precautions are used with Standard Precautions to reduce the risk of MDRO transmission during high-contact resident care activities and include the use of both gowns and gloves. The manual also stated that these precautions apply to residents with indwelling medical devices and are meant to remain in place for the duration of the resident’s stay or until the device is discontinued or the wound resolves. Resident #36 had been readmitted with a tracheostomy, and a sign outside the room indicated Enhanced Barrier Precautions. PPE, including gown and gloves, was available outside the room. During observed tracheostomy care, Nurse #1 performed hand hygiene and donned gloves but did not put on a gown or other required PPE. Immediately afterward, the nurse acknowledged awareness that the resident was on Enhanced Barrier Precautions and responded, "oh yeah," when asked why a gown was not worn. The DON and ADON both stated that the nurse should have worn the required PPE during the procedure, and the Medical Director stated that nursing staff should perform the procedure according to facility policy or protocol.
Failure to Provide Proper CPR and Airway Management for Tracheostomy Patient with Passy-Muir Valve
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate basic life support, including CPR and airway management, to a tracheostomy-dependent resident who was a full code. The resident had multiple respiratory-related diagnoses, including respiratory failure with hypoxia, tracheostomy status, COPD, tracheomalacia, stridor, and a history of recurrent airway concerns. She used a Passy-Muir one-way speaking valve and had physician orders for full code status, routine tracheostomy care with suctioning every shift and as needed, and scheduled nebulized bronchodilator treatments. The manufacturer’s instructions for the Passy-Muir Valve specified that the valve should be removed if the patient exhibited signs of respiratory distress and that it was contraindicated when the patient was unconscious. The facility’s tracheostomy/CPR policy required staff to assess consciousness, call 911, check breathing and pulse, assess the tracheostomy for plugging or dislodgement, suction as needed, and provide rescue breaths via a resuscitation bag to the tracheostomy. On the night of the event, the assigned nurse documented that around midnight she performed tracheostomy care, removed the Passy-Muir Valve, and did not need to suction at that time. Later, around 5:00–5:15 a.m., she again provided medications, tracheostomy care, a nebulizer treatment, and light suctioning of a small amount of clear secretions, then replaced the Passy-Muir Valve. Vital signs at that time included a respiratory rate of 18 and oxygen saturation of 96% on 2 L via trach collar, and the resident was described as alert, oriented, and talkative with no complaints. Around 6:00–6:15 a.m., two nurse aides entered the resident’s room to provide incontinence care and found her unresponsive and not breathing; one aide reported finding no pulse, while the nurse later stated she initially found the resident warm with a faint pulse. The aides left the resident and went to the nurses’ station to notify the nurse, and the nurse went to the room, briefly assessed the resident, then returned to the nurses’ station to verify code status and figure out how to call a Code Blue overhead. After the Code Blue was called, staff brought the emergency cart and backboard to the room and initiated CPR. Multiple staff interviews consistently indicated that chest compressions were started and that a nurse aide was instructed by the nurse to use the resuscitation bag over the resident’s mouth and nose, not over the tracheostomy. Staff also reported that the nurse did not assess the tracheostomy, did not remove the Passy-Muir Valve, and did not suction the tracheostomy during the code, despite the resident having a tracheostomy and a Passy-Muir Valve in place. The nurse later confirmed she did not check the tracheostomy airway or remove the Passy-Muir Valve at any point and clarified that the resuscitation bag was kept over the resident’s mouth for all respirations. When EMS arrived, they found staff performing CPR with an AED attached and a resuscitation bag being used over the mouth without oxygen. EMS removed the Passy-Muir Valve, noted it was filled with secretions and buildup, and found the tracheostomy tube plugged, requiring multiple rounds of deep suctioning before effective ventilation through the tracheostomy could be achieved. The Medical Director and the Passy-Muir company’s clinical representative both stated that respirations during CPR for a tracheostomy patient must be provided at the tracheostomy site and that the Passy-Muir Valve should be removed when the patient is in respiratory distress or unconscious. The resident was transported to the hospital, where records documented a large mucus plug in the tracheostomy and listed acute on chronic respiratory failure with anoxic brain injury, mucus plug, and tracheal stenosis status post tracheostomy as causes on the death certificate.
Inaccurate MDS Assessments for Cognition, Mood, and Discharge
Penalty
Summary
The facility failed to accurately complete the Minimum Data Set (MDS) assessments for two residents, leading to deficiencies in coding cognition, mood, and discharge destination. Resident #58, who was admitted with chronic kidney disease, had an MDS assessment indicating he was rarely/never understood, yet the staff assessments for cognition and mood were not completed. The facility's Social Worker, responsible for these sections, was unaware of the requirement to complete a staff assessment if the resident could not be understood, despite having received some training from the corporate MDS consultant. The Administrator acknowledged that the assessment should have been completed accurately. For Resident #70, the discharge MDS was incorrectly coded as discharged to an acute hospital, while a progress note indicated the resident was transported home. The MDS Coordinator admitted the error in coding the discharge destination, and the Director of Nursing confirmed that the discharge MDS should accurately reflect the resident's discharge status. The Administrator also indicated that the MDS should be completed accurately, highlighting the facility's failure to ensure accurate documentation of resident assessments.
Failure to Apply Palm Guard for Resident with Hemiplegia
Penalty
Summary
The facility failed to apply a left-hand palm guard for a resident with hemiplegia and hemiparesis following cerebrovascular disease, contracture in the left hand, and dementia. The resident was moderately cognitively impaired and had impairments on one side of her upper and lower extremities. Observations revealed that the resident's left hand was often without the prescribed carrot palm guard, which was intended to protect the skin from moisture, pressure, and nail puncture injuries. Despite a physical therapy note instructing staff to keep the carrot in the resident's left hand except during bathing, the carrot was frequently found in a basket on the bedside table instead of in the resident's hand. Interviews with staff indicated that the resident was sometimes resistive to care, and there was no documentation of the resident's refusal to have the carrot placed in her hand. The Physical Therapy Director confirmed that the resident was to have the carrot placed in her left hand and that the nursing staff had been in-serviced on this procedure. However, the Director of Nursing was unaware of the situation and stated that the nursing staff should have documented any refusals. The lack of consistent application of the palm guard and failure to document refusals contributed to the deficiency in care for the resident.
Failure to Maintain a Clean and Homelike Environment
Penalty
Summary
The facility failed to provide a clean and homelike environment in one of the resident rooms, as observed and reported by a family member and staff. During an interview, a family member expressed concerns about the condition of the ceiling vent in the resident's room. An observation revealed that the area around the ceiling vent was in disrepair, with a black substance on one side and signs of possible water damage repaired with a white spackle-like substance. The Maintenance Director confirmed that vent inspections were conducted once or twice a month, but no work order was found for the ceiling vent in question. Upon visual inspection, the Maintenance Director acknowledged that the damage, likely due to condensation, had been overlooked. The Administrator stated that it was expected for maintenance staff to conduct inspections and make necessary repairs.
Misappropriation of Controlled Substances in LTC Facility
Penalty
Summary
The facility failed to protect a resident's right to be free from misappropriation of property, specifically involving the mishandling of controlled substances. A resident was admitted to the facility and later expired, during which time their medications, including Oxycodone HCL, Lorazepam, Ultram, and Morphine Sulfate, were supposed to be returned to the pharmacy. However, the process was not followed correctly, leading to the misappropriation of a card containing 30 Oxycodone HCL 5 mg tablets. The Unit Manager (UM) and Assistant Director of Nursing (ADON) initially completed a Return of Drug form and placed the medications in a sealed bag. The UM attempted to fax the form to the pharmacy but did not verify its receipt. The medications were left in the locked narcotic drawer of the medication cart, and the control bag number on the Return of Drug form was later found to be altered. The UM discovered the discrepancy when a nurse informed her of the medications still being in the cart, but she did not immediately notify the Director of Nursing (DON). Upon further investigation, it was found that the medications had been transferred to a new sealed bag with a different control number, and the Return of Drug form was altered to match this new number. The DON and UM confirmed the missing Oxycodone tablets after opening the bag. The facility's policy required immediate return of controlled substances upon discontinuation, discharge, or death of a resident, which was not adhered to in this case.
Medication Administration Error Due to Dosage Confusion
Penalty
Summary
The facility failed to administer medications to a resident as ordered, resulting in the resident receiving an incorrect dose of Oxycodone Hydrochloride (HCL) on two separate occasions. The resident, who was admitted with diagnoses including osteomyelitis of the vertebra, left elbow pain, and trigeminal neuralgia, was prescribed Oxycodone HCL 10 mg to be administered every 4 hours for chronic osteomyelitis. However, on May 17 and May 18, the resident received only 5 mg of Oxycodone HCL instead of the prescribed 10 mg. This discrepancy was due to confusion about the dosage by the medication aides responsible for administering the medication. The narcotic controlled substance count record and the Medication Administration Record (MAR) showed inconsistencies in the dosage administered. Medication Aide #1 admitted to administering only 5 mg on May 17 due to confusion, while attempts to interview Medication Aide #4 were unsuccessful. The Director of Nursing and the Administrator both expressed that their expectation was for residents to receive the correct dosage of medications, highlighting a failure in meeting professional standards of quality in medication administration.
Failure to Post Oxygen Signage for Resident on Supplemental Oxygen
Penalty
Summary
The facility failed to post cautionary signage outside a resident's room to indicate the use of supplemental oxygen. This deficiency was identified for a resident who was admitted with acute respiratory failure with hypoxia and chronic obstructive pulmonary disease. The resident had a physician's order for oxygen supplementation at 2 liters via nasal cannula or mask if oxygen saturation was less than 90%. Observations on multiple occasions revealed that the resident was using a nasal cannula for supplemental oxygen, but there was no signage outside the room indicating the use of supplemental oxygen. Interviews with facility staff, including a nurse, the unit manager, and the Director of Nursing, confirmed that it was standard procedure to place an oxygen sign on the door of any resident receiving oxygen therapy upon admission or when there was a change in condition requiring new oxygen therapy. Despite this protocol, the required signage was not placed on the resident's door, indicating a lapse in following established procedures for respiratory care safety measures.
Medication Cart Left Unlocked and Unattended
Penalty
Summary
The facility failed to secure residents' medications in a locked medication cart, as observed with the Station 1 medication cart. During a continuous observation, the medication cart was found unlocked and unattended in the hallway outside the nurse's station. There were no medications on top of the cart, and no nurse was present at the station or in the nursing station. Staff were observed in the adjacent hallway, but no residents were present. Nurse #7 later approached the cart, observed the surveyor, and locked the cart. During an interview, Nurse #7 admitted to leaving the cart unlocked and stated that it should be locked when unattended. The Director of Nursing confirmed that the medication cart should be locked at all times when not attended by a nurse.
Inaccurate Medication Record Keeping for Oxycodone Administration
Penalty
Summary
The facility failed to ensure the accuracy of medical records concerning the administration of Oxycodone Hydrochloride (HCL) for a resident. The resident, who was admitted with conditions including osteomyelitis of the vertebra, had a physician's order for Oxycodone HCL 10 mg to be administered every 4 hours. However, discrepancies were found in the narcotic controlled substance count record and the Medication Administration Record (MAR). Specifically, the narcotic count record showed that only 5 mg doses were signed out on two occasions, while the MAR documented that 10 mg doses were administered. Interviews with staff revealed further inconsistencies. Medication Aide #1 confirmed administering only 5 mg of Oxycodone HCL on one occasion, contradicting the MAR entry. Attempts to interview Medication Aide #4 were unsuccessful. Both the Director of Nursing and the Administrator expressed expectations that medical records should accurately reflect the correct dosage of medications administered to residents, highlighting a failure in maintaining accurate medical records for the resident in question.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Ayden
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Macgregor Downs Health Center By Harborview | 10.1 mi | ★★★★★ | 3 | 0 |
| Greenville Health And Rehabilitation Center | 10.6 mi | ★★★★★ | 0 | 0 |
| East Carolina Health And Rehabilitation Center | 10.7 mi | ★★★★★ | 14 | 0 |
| Cypress Glen Retirement Community | 10.8 mi | ★★★★★ | 0 | 0 |
| Pruitthealth-farmville | 11.8 mi | ★★★★★ | 5 | 0 |
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