Citations in North Carolina
Comprehensive analysis of citations, statistics, and compliance trends for long-term care facilities in North Carolina.
Statistics for North Carolina (Last 12 Months)
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Latest Citations in North Carolina
A resident with Type 2 DM, cognitively intact and receiving weekly tirzepatide (Mounjaro) injections, had four pens delivered and stored in a locked refrigerator, treated like narcotics. When an RN attempted to administer the scheduled weekly dose, the first pen retrieved was already unlocked with the cap depressed and no medication available, and a second pen for the same resident was found in the same empty, used state. The resident reported that two pens were empty when the nurse tried to give the injection and that the dose was given several days late after new medication was obtained. The UM, Wound Nurse, and other staff confirmed both pens appeared used when compared to another resident’s unused pen, while pharmacy and manufacturer representatives indicated such defects would typically be detected before shipment. Multiple nurses and leadership could not explain why the pens were empty, and leadership acknowledged they did not initially consider or report potential misappropriation of the resident’s medication.
A cognitively intact resident with Type 2 DM had two tirzepatide (Mounjaro) pens found empty when a nurse attempted to administer the scheduled weekly injection, requiring replacement medication from the pharmacy and resulting in a delayed dose. The nurse and UM confirmed both remaining pens for this resident were already activated and empty, based on comparison with another resident’s unused pen. Although facility policy required immediate investigation and reporting of suspected abuse, neglect, exploitation, or misappropriation to the Administrator, State Agency, APS, and other agencies, no formal investigation into the empty pens was conducted and no report of potential misappropriation was made to the State Agency or other required entities.
A wound nurse failed to consistently follow the facility’s hand hygiene policies while performing multiple pressure ulcer treatments on a resident. Although the nurse initially washed her hands and donned appropriate PPE, she repeatedly removed soiled gloves and applied clean gloves without performing required hand hygiene between several steps of the wound care on the hip and sacral areas. In interviews, the nurse acknowledged she knew hand hygiene was required between glove changes but stated she lost track due to multiple glove changes and nervousness while being observed, while the IP and Administrator confirmed that policy requires hand hygiene every time gloves are removed.
The facility failed to request required Level II PASRR evaluations for four residents who developed new mental health diagnoses after admission. Each resident had a pre-admission Level I PASRR that directed the facility to resubmit paperwork for a Level II if new mental health conditions or significant changes occurred, yet subsequent MDS assessments documented new active diagnoses such as psychotic disorder, major depressive disorder, anxiety disorder, schizoaffective disorder, bipolar type, and autism without any corresponding Level II PASRR requests. The SW reported she was responsible for PASRR paperwork but had not received training on when and how to complete and submit Level II requests and was unaware they were required for new mental health diagnoses or significant changes, while the Administrator confirmed the SW’s responsibility and acknowledged that Level II PASRR evaluations had not been completed as expected for these residents.
During a COVID-19 outbreak, the facility failed to follow its own policies and CDC guidance for infection prevention and control. Staff entered a COVID-positive resident’s TBP room and performed COVID specimen collection without required eye protection, despite clear signage and available PPE. The facility did not have a specific policy for PPE during COVID specimen collection, and a UM reported uncertainty about eye protection requirements. Staff with COVID-19 were allowed to return to work before 10 days from symptom onset without documented negative viral tests on both day 5 and day 7, and there was no systematic logging or oversight of staff self-testing. COVID-positive residents were removed from TBP after 7–9 days based on a single negative antigen test on day 5, contrary to the policy requiring 10 days or two negative tests 48 hours apart. The facility also used expired COVID-19 test kits for staff and resident testing, despite manufacturer confirmation that the printed expiration dates were final and that results from expired tests would not be valid.
Surveyors found that the facility failed to educate cognitively intact residents on the benefits and potential side effects of the COVID-19 vaccine, did not consistently offer the vaccine, and did not document offers, consents, or declinations in the medical record. Multiple residents had MDS assessments indicating they were not up to date on COVID-19 immunization, with no vaccination history or related education documented, and they reported not recalling any discussion or offer of the vaccine. The IP nurse used an informal list to track interest, lacked a defined process for new admissions, and did not provide risk-versus-benefit education, while the formal admission and documentation processes in place for flu and pneumonia vaccines did not include COVID-19, resulting in absent medical record documentation for COVID-19 vaccination activities.
A resident with bladder neck obstruction and an indwelling urinary catheter had care plan interventions and medical orders in place, including securing the catheter to prevent excess tension and routine flushing for sediment. During observation, the catheter was connected to a bedside drainage bag with visible urine and sediment, but no catheter stabilization device was present. A NA had noticed the missing device earlier and reported it to the assigned nurse, who assessed the catheter but delayed replacing the device while awaiting input from the NP about a possible catheter change. The ADON later assessed the resident and confirmed the absence of the stabilization device, while the NP and Administrator both indicated the resident should have had a device in place to prevent pulling of the catheter tubing.
A resident with a documented history of type 2 DM and generalized anxiety disorder did not have these conditions accurately coded on the annual MDS. Although the care plan addressed DM and physician documentation showed diet-controlled DM and an order for daily Ativan for anxiety and mood disorder, the MDS omitted both DM and anxiety as active diagnoses while still indicating use of an antianxiety medication and severe cognitive impairment. The MDS nurse later acknowledged that the resident’s DM and anxiety diagnoses should have been coded and that their omission was an oversight, and the Administrator confirmed that all diagnoses should be reflected on the MDS.
A resident was admitted with medical diagnoses and a Level I PASRR that showed no mental illness and did not trigger Level II criteria. Over time, the resident’s record was updated to include generalized anxiety disorder, depressive disorder, and later a psychiatrist-documented mood disorder with psychosis/bipolar, with Zyprexa prescribed and bipolar disorder coded on the MDS. Despite these new serious mental illness diagnoses, no Level II PASRR request was found in the record. The MDS Coordinator reported she did not notify the Business Office Manager (who is responsible for submitting Level II PASRR requests) when the new mental health diagnoses were added, and the Business Office Manager confirmed she was never informed of these diagnoses.
Surveyors found that staff failed to manage food items appropriately in two nourishment room refrigerators, where multiple expired products and unlabeled, undated beverages were stored. In the main nourishment room, there were outdated strawberry preserves, a high-protein milkshake, and nutritional energy drinks, along with several partially filled drink containers that lacked labels and dates. In the locked unit nourishment room, surveyors observed expired yogurt and prepackaged apples, with some apples showing visible spoilage. Nursing staff and unit leadership acknowledged that nurses were responsible for labeling, dating, and discarding expired items, and facility leadership stated they expected staff to ensure all nourishment room food was properly labeled and free of outdated items.
Failure to Safeguard Resident’s Tirzepatide Pens From Misappropriation
Penalty
Summary
The deficiency involves the facility’s failure to protect a cognitively intact resident’s right to be free from misappropriation of medication, specifically tirzepatide (Mounjaro) prescribed for Type 2 diabetes mellitus. The resident had a physician’s order for a weekly subcutaneous injection of tirzepatide 5 mg/0.5 ml on Fridays. Pharmacy records showed that four tirzepatide injections (2 ml total) were delivered and charged to the resident’s insurance. The pens were stored in a locked box in the medication room refrigerator and treated like narcotics. Multiple nurses confirmed that the pens were received and placed in the refrigerator, with at least one nurse stating she visually confirmed that the pens contained medication at the time of delivery. On the scheduled administration date, the assigned nurse retrieved a tirzepatide pen from the refrigerator to give the resident her weekly injection and found the pen already unlocked with the purple cap depressed and no medication available to inject. After involving the Wound Nurse and the Unit Manager, they inspected the remaining tirzepatide pen for the resident and discovered that it was also empty, with the purple cap depressed and the plunger visible, indicating the medication had already been expressed. The resident reported that the nurse attempted to give the weekly tirzepatide injection but found the syringe empty, then obtained another syringe that was also empty. The resident stated she ultimately received the injection two or three days later after additional medication was obtained, and that while she had previously experienced delays waiting for pharmacy delivery, she had never before encountered empty pens when nurses attempted to administer the medication. The Unit Manager, acting as DON at the time, compared the two empty pens to another resident’s tirzepatide pen and confirmed that the empty pens appeared used, with the purple caps depressed, unlike the unused pen. The Unit Manager notified the Administrator, Regional Clinical Manager, and NP that the pens were empty and contacted the pharmacy to request replacement medication. The pharmacy manager stated that the resident’s insurance was billed for the pens, that the pens are individually labeled and repackaged by the pharmacy, and that any damaged or empty pens would typically be identified before shipment. A manufacturer representative also stated that while pens could potentially leak, such issues would likely be noticed by the pharmacy during repacking. Multiple nurses, including those who had administered prior and subsequent tirzepatide doses, reported no prior issues with empty pens and could not explain why the two pens for this resident were empty. The Unit Manager and Administrator both acknowledged they did not initially consider misappropriation of medication when the empty pens were discovered, despite the medication being described as expensive and highly sought after.
Failure to Report and Investigate Possible Misappropriation of Tirzepatide
Penalty
Summary
The deficiency involves the facility’s failure to implement its abuse, neglect, and exploitation policy regarding reporting and investigating a suspected misappropriation of a resident’s medication. The facility’s written policy required immediate investigation when there was suspicion or reports of abuse, neglect, exploitation, or misappropriation of resident property, and mandated reporting all alleged violations to the Administrator, State Agency, Adult Protective Services, and other required agencies within specified timeframes. Despite these requirements, when empty tirzepatide (Mounjaro) pens belonging to a resident were discovered, the facility did not initiate an abuse/misappropriation investigation or report the incident to the State Agency or other required entities. The resident involved was cognitively intact and had a diagnosis of diabetes mellitus, with a physician’s order for weekly subcutaneous tirzepatide injections for Type 2 diabetes. The resident reported that on one occasion a nurse attempted to administer the weekly tirzepatide injection, but the syringe was empty, and when another syringe was obtained from the refrigerator, that syringe was also empty. The resident stated that she ultimately received her weekly injection, but it was administered two or three days late after medication was obtained from the pharmacy. She also reported that she had not previously experienced an issue with empty syringes when nurses attempted to give her the injection. Staff interviews confirmed that on the morning in question, the nurse assigned to the resident retrieved a tirzepatide pen from the refrigerator and found it already unlocked with the purple cap depressed, indicating it was empty. The Unit Manager, who was acting as DON at the time, verified that both remaining pens for this resident were empty by comparing them to another resident’s unused tirzepatide syringe. The Unit Manager notified the Administrator and Regional Clinical Manager and contacted the pharmacy, but she did not consider the possibility of misappropriation and did not initiate an investigation into how or why the pens were empty. The Administrator acknowledged being informed of the empty pens but did not seek further details, did not ensure an investigation was conducted, and did not recognize or report the situation as a potential misappropriation, despite the facility’s policy requiring such reporting and investigation.
Failure to Perform Hand Hygiene Between Glove Changes During Wound Care
Penalty
Summary
The deficiency involves the facility’s failure to follow its own hand hygiene policies during wound care for Resident #10. The facility’s Hand Hygiene and Basics of Hand Hygiene policies require staff to perform hand hygiene before applying and after removing PPE such as gloves, and before and after providing any type of care. During an observed wound care session, the Wound Nurse prepared supplies on a disinfected over-bed table with a protective barrier, washed her hands, and donned a gown and gloves before starting treatment. As the resident was positioned on her right hip to expose a left hip wound, the Wound Nurse removed the soiled dressing, removed her gloves, and then applied clean gloves without performing hand hygiene. She then cleansed the wound, applied skin prep, removed her gloves, sanitized her hands, and applied clean gloves before placing a foam dressing. After that, she again removed her gloves but did not perform hand hygiene before putting on another pair of clean gloves. The resident was then repositioned to expose sacral and right hip wounds. For the sacral wound, the Wound Nurse removed the dirty dressing, removed her gloves, and performed hand hygiene before donning clean gloves and cleansing the wound. She then removed her dirty gloves and again applied clean gloves without performing hand hygiene, applied soaked gauze and a foam dressing, then removed her gloves and performed hand hygiene before donning clean gloves. For the right hip wound, the Wound Nurse removed the dirty dressing, removed her gloves, and washed her hands before applying clean gloves and cleansing the wound. She then removed her dirty gloves and applied clean gloves without performing hand hygiene, applied soaked gauze and a foam dressing, and finally removed her gloves and performed hand hygiene. In interviews, the Wound Nurse acknowledged she did not realize she had failed to perform hand hygiene between some glove changes, stated she knew she was supposed to, and attributed the lapses to losing track due to multiple glove changes and being nervous under observation. The Infection Preventionist and Administrator both confirmed that facility policy and expectations require hand hygiene every time gloves are removed, regardless of visible soiling.
Failure to Request Level II PASRR Evaluations for Residents With New Mental Health Diagnoses
Penalty
Summary
The facility failed to submit required Level II Preadmission Screening and Resident Review (PASRR) evaluations for multiple residents who developed new mental health diagnoses after admission. Record review showed that four residents each had a PASRR Level I completed prior to admission, with explicit recommendations to resubmit paperwork for a Level II PASRR if a new mental health diagnosis was suspected or if there was a significant change in condition. For one resident, the quarterly MDS documented active diagnoses of psychotic disorder and major depressive disorder that were established after admission, yet there was no evidence of a Level II PASRR request. Another resident’s quarterly MDS reflected active diagnoses of anxiety disorder, major depressive disorder, and schizoaffective disorder, bipolar type, all diagnosed after admission, with no corresponding Level II PASRR request in the record. A third resident’s annual MDS documented active diagnoses of psychotic disorder, anxiety disorder, and major depressive disorder, all diagnosed after admission, without any evidence that a Level II PASRR evaluation had been requested. A fourth resident’s quarterly MDS showed active diagnoses of autism, psychotic disorder, and anxiety disorder, again with no documentation of a Level II PASRR request despite the pre-admission Level I instruction to resubmit if new mental health diagnoses occurred or there was a significant change. In interviews, the Social Worker stated she believed she was responsible for PASRR Level II paperwork but had not received training on when and how to complete and submit it, and she was unaware that Level II PASRR paperwork was required for new mental health diagnoses, significant changes, or expiring temporary Level II determinations. The Administrator confirmed that the Social Worker was responsible for PASRR paperwork, acknowledged the Social Worker had not received full PASRR training, and stated his understanding that Level II PASRR evaluations should be completed upon admission or readmission with a mental health diagnosis and with any new mental health diagnosis or change in condition, which had not occurred for the sampled residents.
Failure to Follow COVID-19 PPE, Isolation, Testing, and Test-Expiration Requirements During Outbreak
Penalty
Summary
The deficiency involves the facility’s failure to follow its own infection prevention and control policies and current CDC guidance during an ongoing COVID-19 outbreak. The facility policy required staff entering rooms of residents with suspected or confirmed COVID-19 to use an N95 or higher-level respirator, gown, gloves, and eye protection. One resident who tested positive for COVID-19 was placed on transmission-based precautions (TBP) with a door sign specifying gown, gloves, N95, and eye protection. A nurse aide entered this resident’s room wearing a gown, gloves, and mask but without eye protection, and there was no eye protection available on the PPE caddy outside the room. The nurse aide stated she believed her eyeglasses counted as eye protection. The infection prevention (IP) nurse, ADON, Administrator, and Regional Nurse all confirmed that full PPE, including eye protection, was required and that staff had been educated, but they could not explain why the nurse aide did not comply. The facility also failed to ensure appropriate PPE use during COVID-19 specimen collection. CDC interim guidelines for collecting and handling clinical specimens for COVID-19 require an N95 or higher-level respirator, eye protection, gloves, and gown for healthcare providers collecting specimens or working within 6 feet of patients suspected to be infected. The facility did not have a policy addressing PPE for COVID-19 specimen collection. During observation of resident COVID testing, one unit manager collecting nasal swabs wore an N95, gown, and gloves but did not wear eye protection, while another unit manager handling the specimens in the hallway wore an N95 and gloves. The IP nurse and ADON stated that full PPE, including eye protection, should be worn for COVID testing and that the facility had an adequate supply of face shields. The unit manager who collected the specimen reported she was unsure if eye protection was required and only obtained face shields after consulting someone from corporate. The facility failed to follow CDC return-to-work criteria for staff with COVID-19 and did not maintain adequate records of staff testing. The facility’s policy referenced CDC interim guidance for managing healthcare personnel with COVID-19 infection, which requires at least 7 days since symptom onset with a negative viral test within 48 hours prior to return (or 10 days if testing is not performed or if the day 5–7 test is positive), and, if using antigen tests, negative tests on day 5 and again 48 hours later. Review of the facility’s COVID-positive staff log showed 12 staff had tested positive, and 9 returned to work before 10 days from symptom onset without documentation of negative tests on both day 5 and day 7. The IP nurse stated staff were tested with antigen tests on day 5 and allowed to return to work on day 7 if that test was negative, and that she did not perform or document a second test on day 7. She also stated staff performed self-testing, that tests were placed in the break room or taken home, and that there was no process to track when staff tested, whether they tested as required, or whether tests were performed according to manufacturer instructions. The facility Physician and Administrator stated the facility should follow its infection control policies and CDC guidance, and the Administrator acknowledged there was no oversight or logging of staff COVID test results. The facility also failed to maintain TBP for COVID-positive residents in accordance with its policy and CDC guidance. The facility’s policy required residents with mild to moderate illness who were not moderately to severely immunocompromised to remain on TBP for at least 10 days after symptom onset, with additional criteria for severe illness and for test-based strategies requiring two negative tests 48 hours apart. Review of the COVID-positive resident log showed that multiple residents were removed from TBP after 7–9 days from symptom onset, rather than after the full 10 days. The IP nurse stated residents were tested with antigen tests on day 5 and, if negative, were removed from TBP after 7 days; if positive on day 5, TBP continued for 10 days. She reported she did not perform a second test on day 7 before discontinuing TBP and was unaware that two negative tests 48 hours apart were required when using a testing strategy. She also stated that TBP orders were entered for 10 days in the electronic system but were not discontinued when residents were taken off precautions earlier. Additionally, the facility used expired COVID-19 test kits for resident and staff testing during the outbreak and did not follow manufacturer expiration dates. Observations in the staff break room showed boxes of two different brands of COVID tests with expiration dates already passed. The IP nurse stated three brands of COVID tests, all with listed expiration dates that had passed, were used for staff and resident testing during the outbreak and that she believed the tests could be used for six months beyond the printed expiration date. Customer service representatives for each test manufacturer confirmed that the lot numbers in question did not have extended expiration dates, that the printed expiration dates were final, and that tests used after those dates would not be considered accurate or valid, with potential for false negative or false positive results. The Health Department nurse stated the facility had recently contacted them about using expired tests and that the department was working on guidance. The facility Physician stated that using expired COVID tests could affect test efficacy, that the protein in the test solution breaks down over time, and that expired tests could produce false negative results.
Failure to Educate, Offer, and Document COVID-19 Vaccination for Residents
Penalty
Summary
The deficiency involves the facility’s failure to educate residents on the benefits and potential side effects of the COVID-19 vaccine, to offer the vaccine, and to document vaccination status and related education in the medical record. Five cognitively intact residents were identified whose Minimum Data Set (MDS) assessments showed they were not up to date with COVID-19 immunization and whose records contained no history of COVID-19 vaccination. For each of these residents, there was no documentation that the COVID-19 vaccine had been offered or that education regarding the benefits and potential side effects of the vaccine had been provided. Resident #3, Resident #16, Resident #99, Resident #117, and Resident #127 were all cognitively intact per their respective MDS assessments and were coded as not up to date for COVID-19 immunization. Record review for each resident revealed no COVID-19 vaccination history and no documentation of an offer of the vaccine or provision of education on its benefits and potential side effects. In interviews, each resident reported not remembering any discussion, offer, or education from the facility regarding the COVID-19 vaccine. Some residents stated they would not want the vaccine, some were unsure, and one resident indicated he would probably take it if it were offered, but these preferences were not documented in the medical record. Interviews with facility staff revealed systemic process gaps related to COVID-19 vaccination. The Infection Preventionist (IP) nurse stated she offered the COVID-19 vaccine annually and tracked resident interest using a personal list marked with "Y" or "N" but did not maintain formal documentation of consent or declination in the medical record. She reported that the Admissions Coordinator obtained electronic consent forms for influenza and pneumonia vaccines, which were uploaded into the medical record and reviewed by nursing staff, but this process did not include COVID-19 vaccination. The IP nurse acknowledged she did not have a defined process for offering COVID-19 vaccination to new admissions, was unsure if it was consistently offered, and did not provide risk-versus-benefit education, only side-effect education. The ADON reported relying on the IP nurse to manage COVID-19 vaccination, and the Administrator stated he expected all consents, declinations, and vaccinations to be recorded in the residents’ medical records, which was not occurring for COVID-19 vaccines.
Failure to Use Catheter Stabilization Device for Resident With Indwelling Catheter
Penalty
Summary
The deficiency involves the facility’s failure to use a catheter tubing stabilization device for a resident with an indwelling urinary catheter, despite care plan interventions to secure the catheter and prevent excess tension. The resident was admitted with bladder neck obstruction and had an indwelling catheter documented on the quarterly MDS, with orders for catheter changes as needed and routine flushing due to increased sediment. During an observation, the resident’s indwelling catheter was connected to a bedside drainage bag with visible yellow urine and sediment, and no catheter stabilization device was in place. The Assistant Director of Nursing (ADON), upon assessing the resident, confirmed that there was no device securing the catheter tubing and acknowledged that the resident should have had one in place to keep the catheter from being pulled. A nurse aide reported that on the morning of the same day, when she put the resident back to bed, she noticed the absence of a catheter stabilization device and informed the assigned nurse. The nurse aide stated the resident usually had such a device and that nurse aides were not permitted to change or replace it. The assigned nurse confirmed she had been told about the missing device, assessed the catheter, and delayed applying a new stabilization device while waiting to speak with the Nurse Practitioner (NP) in case a catheter change was needed. By the time she returned after speaking with the NP, the ADON was already in the process of changing the catheter. The NP stated she believed it was protocol for the resident to have a catheter stabilization device to prevent pulling of the catheter tubing and noted that pulling or tugging could cause trauma or pain. The Administrator also stated that if something was recommended to prevent the catheter tubing from being pulled, it should have been in place.
Inaccurate MDS Coding for Diabetes and Anxiety Diagnoses
Penalty
Summary
The facility failed to ensure an accurate MDS assessment for one resident by not correctly coding documented diagnoses of diabetes and anxiety. The resident, who had a medical history significant for type 2 diabetes mellitus and generalized anxiety disorder, was care planned for diabetes but not for anxiety. A physician encounter note documented diet-controlled diabetes mellitus, and a physician order directed administration of Ativan 0.5 mg once daily in the evening for anxiety and an unspecified mood disorder. Despite this documentation and the resident being coded on the annual MDS as cognitively severely impaired and receiving an antianxiety medication, the annual MDS did not include diabetes or anxiety as active diagnoses. In interviews, the MDS nurse acknowledged that these diagnoses were present and should have been coded on the annual MDS, stating that their omission was an oversight, and the Administrator confirmed that all resident diagnoses, including diabetes and anxiety, should have been reflected on the MDS.
Failure to Request Level II PASRR After New Serious Mental Illness Diagnoses
Penalty
Summary
The facility failed to submit a request for a Level II Preadmission Screening and Resident Review (PASRR) evaluation for a resident who developed serious mental health diagnoses after admission. The resident was admitted with medical diagnoses including hypertension, hyperkalemia, and hyperlipidemia, and a Level I PASRR completed on 11/01/2021 indicated no mental health diagnosis and did not meet Level II criteria. Later, the active diagnosis list showed generalized anxiety disorder and depressive disorder as active beginning 03/26/2025, and a psychiatrist’s note dated 01/20/2026 documented a presenting problem of mood disorder with psychosis/bipolar, with Zyprexa 5 mg PO at bedtime prescribed for this condition. The MDS assessment reflected a diagnosis of bipolar disorder but indicated the resident was not considered by the state Level II PASRR process to have serious mental illness or intellectual disability/related condition. Record review and staff interviews revealed that no request for a Level II PASRR evaluation was found in the resident’s electronic or paper medical record despite these new mental health diagnoses. The MDS Coordinator stated that her usual practice was to notify the Business Office Manager (BOM) when residents received new mental illness diagnoses so the BOM could submit a Level II PASRR request to the state agency, but she acknowledged she failed to notify the BOM when the resident’s new mental health diagnoses were added in March 2025. The BOM confirmed she was responsible for requesting Level II PASRR evaluations and reported she had not been informed of the resident’s anxiety disorder, depressive disorder, or later bipolar disorder diagnosis. The Administrator stated that the Level I PASRR received after admission showed no mental illness and that the Level II PASRR evaluation should have been completed when the new mental illness diagnoses were added in March 2025.
Expired and Unlabeled Food Items in Nourishment Room Refrigerators
Penalty
Summary
Failure to properly manage food storage in nourishment room refrigerators occurred when staff did not discard expired or spoiled food items and did not label and date resident personal food items. In the Main Unit nourishment room refrigerator, surveyors observed a partially used jar of strawberry preserves with a use-by date that had passed, an unopened high-protein milkshake with a best-if-used-by date that had passed, and three unopened bottles of a nutritional energy drink with a use-by date that had passed. Additionally, there were multiple beverage containers, including a 2-liter soft drink bottle half full of an orange liquid, and two 500-milliliter bottles containing purplish and brownish liquids, none of which were labeled or dated. Staff present during the observation acknowledged that nursing staff were supposed to ensure all nourishment refrigerator items were labeled, dated, and that expired items were discarded. In the Locked Unit nourishment room refrigerator, surveyors observed a cup of yogurt with an expiration date that had passed and a package of three prepackaged apples with an opened-by and best-by date that had passed, with two apples showing grayish fuzz. The Locked Unit Charge Nurse stated that nurses were responsible for labeling food items, checking expiration dates, and that she should have checked the refrigerator at the beginning of her shift to ensure expired items were discarded to prevent foodborne illnesses. The DON and the Administrator both stated their expectation that nursing staff inspect nourishment refrigerators to ensure there were no outdated items and that all food items were labeled and dated.
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