Central Continuing Care: Pressure Sore Prevention Lapse - NC
A wheelchair cushion assigned to Resident #30 at Central Continuing Care went missing for an indeterminate period, and when federal inspectors arrived on a complaint visit in September 2025, not one staff member could pinpoint when they had last confirmed it was in place.
The cushion mattered. Residents who spend hours in wheelchairs without pressure-relief cushions are at risk for pressure injuries, the kind that begin as redness and can progress, in vulnerable patients, to open wounds. The cushion for Resident #30 was listed on the Kardex, the working care record that nursing staff consult daily. It was supposed to be there. At some point, it wasn't.
Nurse Aide #4, interviewed on the morning of September 10, said she remembered Resident #30 having a cushion in the wheelchair but could not recall when she had last actually seen it. She described the general practice: cushions stayed in the chair, and a replacement was pulled only when a soiled cushion went to laundry. That was the system. Whether the system had worked for Resident #30 recently, she couldn't say.
Nurse Aide #11, interviewed about an hour later the same morning, said she did remember seeing a wide black cushion in the wheelchair, but wasn't sure of the exact day. She knew the Kardex listed it. Her understanding of the protocol matched her colleague's: if the cushion wasn't there, you told a nurse and got a replacement from the supply room. Simple enough. But neither aide could confirm that check had happened with any regularity, or at all, in the period before the complaint was filed.
The Director of Nursing, interviewed the following morning, described wheelchair cushions as standard practice from the moment of admission. Three types were available in the supply room, she said, and nurses used their judgment to select the appropriate one. She also acknowledged that staff had been recently in-serviced, after the fact, on the importance of documenting on the Treatment Administration Record once they had verified that a cushion was actually in place. That in-service happened after the problem surfaced. Not before.
What the inspection record does not contain is any documentation that staff had been routinely confirming the cushion's presence and recording it. The Kardex said there should be a cushion. Whether anyone had looked to verify that recently enough to catch its absence is precisely what could not be established.
Inspectors cited the facility under F0686, the federal tag covering pressure ulcer prevention and skin integrity. The level of harm was listed as minimal harm or potential for actual harm, and the finding was described as affecting few residents. No pressure injury to Resident #30 was documented in the inspection narrative.
That absence of documented injury is not the same as no risk having existed.
A resident seated for hours in a wheelchair without the cushion that was prescribed and charted as present was exposed to pressure on bony prominences, the hips, the tailbone, the backs of the thighs, for whatever stretch of time the cushion was missing. How long that was, no one at Central Continuing Care could answer when inspectors asked.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Central Continuing Care from 2025-09-11 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 22, 2026 · Our methodology
Central Continuing Care in Mount Airy, NC was cited for violations during a health inspection on September 11, 2025.
The cushion for Resident #30 was listed on the Kardex, the working care record that nursing staff consult daily.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.