Salisbury Rehabilitation And Nursing Center

F 0561 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

record review, and resident and staff interviews, the facility failed to allow a resident who was assessed as safe to smoke without supervision the choice to smoke at preferred times for 1 of 3 residents reviewed for choices (Resident #50).The findings included:Resident #50 was admitted to the facility on [DATE REDACTED].Review of Resident #50's admission Data Set (MDS) dated [DATE REDACTED] revealed the resident was cognitively intact and was coded for tobacco use.Review of Resident #50's care plan created on 08/16/25 revealed the resident preferred to smoke. The goal was Resident #50 would smoke safely through the review period.

Interventions included Resident #50 could smoke unsupervised.Review of Resident #50's smoking assessments revealed a smoking assessment was completed on 10/08/25. The assessment further revealed Resident #50 was safe to smoke without supervision.An interview with Resident #50 on 12/17/25 at 1:00 PM revealed she was an independent smoker and was able to smoke anytime from 7:00 AM until 8:00 PM. Resident #50 further revealed she would like to be able to smoke after 8:00 PM, but nursing staff would lock the doors going to the smoking area and was unable to smoke. Resident #50 stated she had reported to staff she wanted to be able to smoke after 8:00 PM.An interview with Nurse Aide (NA) #3 on 12/17/25 at 1:15 PM revealed she worked both the 7:00 AM to 3:00 PM shift and 11:00 PM to 7:00 AM shift, and Resident #50 had complained that she was unable to go out after 8:00 PM and smoke. NA #3 further revealed she had been educated by department heads that no residents were allowed outside to smoke after 8:00 PM. NA #3 indicated Resident #50 was a safe independent smoker and had no prior incidents that she was aware of.An interview with the Director of Nursing (DON) on 12/23/25 at 11:38 AM revealed the owner of the building was uncomfortable with residents going outside to smoke after 8:00 PM due to the cold weather. The DON further revealed independent smokers should be allowed to go out to smoke when they preferred. An interview with the Administrator on 12/23/25 at 9:30 AM revealed supervised smokers stopped smoking at 8:00 PM due to lack of staff being available and concerns of cold temperatures. The Administrator stated he was unaware that independent smokers were not allowed outside after 8:00 PM to smoke. The Administrator indicated it must have been carried over by the previous administration, and it would be corrected immediately that independent smokers could smoke after 8:00 PM if they preferred.

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date

these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE

TITLE

(X6) DATE

FORM CMS-2567 (02/99) Previous Versions Obsolete

Facility ID:

If continuation sheet

Event ID:

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

01/02/2026

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Salisbury Rehabilitation and Nursing Center

635 Statesville Boulevard Salisbury, NC 28144

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0602 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

taken 28 tablets in just 5 days. She stated she notified DON #1 immediately.The Hospice Nurse was interviewed by telephone on 12/18/2025 at 2:41 pm and stated she visited Resident #6 on 11/10/2025 and counted Resident #6's oxycodone tablets with Medication Aide (MA) #1. The Hospice Nurse stated she had also visited Resident #6 on 11/5/2025 and she had 28 tablets but on 11/10/2025 she did not have any Oxycodone. The Hospice Nurse stated Resident #6 did not usually take the Oxycodone because she had

an order for another narcotic pain medication (Morphine Sulfate) which was liquid and easier for her to swallow. The Hospice Nurse stated she and Medication Aide #1 reported Resident #6's missing Oxycodone to DON #1 immediately. DON #1 was interviewed on 12/18/2025 at 10:34 am and she stated the 28 tablets of missing oxycodone 5 milligrams for Resident #6 was discovered by MA #1 when she was counting Resident #6's narcotics with the Hospice Nurse. She stated MA #1 notified her immediately of the missing narcotic medication. DON #1 stated neither MA #1 nor Nurse #2 were suspended during the investigation and neither were asked to provide a drug test. DON #1 stated the facility did not drug test staff unless they showed signs of impairment due to drug use.The Pharmacist, from the facility's contracted dispensing pharmacy, was interviewed by telephone on 12/18/2025 at 12:10 pm and she stated the pharmacy did not receive communication that either Resident #22 or Resident #6 had narcotic medications that were missing. The Pharmacist stated the facility would be responsible for investigating and reporting missing medication to the authorities.DON #1 was interviewed on 12/18/2025 at 10:34 am and she stated she began an investigation and submitted a 24 hour report for the 30 tablets of oxycodone to the state agency, police and adult protective service, did an audit of all other resident's narcotic medication cards; educated

the nurses and medication aide on counting of narcotics at the beginning of each shift and counting the number of narcotic medication cards in the cart; and she initiated a new policy that she and the Assistant Director of Nursing (ADON) were the only staff that could remove narcotics that were to be returned to the pharmacy. DON #1stated she had a locked safe installed in her office closet and the closet had a lock for holding medications that should be returned to the pharmacy. DON #1 stated the staff had not been counting the number of cards when they did a narcotic count and when she reviewed the form where the cards should be counted when completing the narcotic count there were days that the count of how many cards should be in the cart had not been done. DON #1 stated she could not determine who had taken the narcotic medication cards that belonged to Resident #22 and Resident #6. DON #1 stated she began a plan of correction for the misappropriation of narcotic medications after Resident #22's narcotics were reported missing and Resident #6's narcotics were reported during the investigation.Administrator #1 was interviewed on 12/19/2025 at 12:57 pm and stated the nursing staff should have counted the narcotics following the facility's policy and ensured there was no missing narcotic medications.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

01/02/2026

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Salisbury Rehabilitation and Nursing Center

635 Statesville Boulevard Salisbury, NC 28144

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few

observations, and staff interviews. Review of audits showed the facility completed new wandering/elopement assessments on all residents. Individual interviews of multiple current staff members working all reported to have completed dementia and behavior de-escalation training since new ownership

on 5/1/25. Record review of the in-service documents dated 12/12/24 and 10/24/25 noted the ADON, the previous DON and the Staff Development Coordinator completed the in-person trainings. Signed staff rosters were reviewed with no issues or concerns. Interviews conducted with multiple staff members revealed they had received training about dementia, behaviors, and the elopement monitoring process, and were able to identify what processes to put into place in the event a resident begins showing increased agitation and wandering.

Observations revealed two hall monitors on

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet