Pisgah Manor Health Care Center

In the surveyor’s words

From the most serious findings on record at Pisgah Manor Health Care Center, in the surveyor’s own words.

• Immediate jeopardy, widespreadF880Apr 1, 2025

  Based on observations, record review, and staff, Medical Director, and Health Department (HD) Nurse interviews, the facility failed to operationalize infection control policy and procedures in accordance with current Centers for Disease Control and Prevention (CDC) guidance. A) The facility failed to implement a broad-based approach to COVID testing for staff and residents when contact tracing testing failed to stop the transmission of COVID. Broad-based COVID testing per the (CDC) guidance was not implemented until 3/25/25. Before broad-based testing was implemented on 3/25/25, a total of 7 staff members and 14 residents tested positive for COVID. Results of the broad-based testing from 3/25/25 to 3/31/25 yielded one (1) staff member and 8 additional residents positive for COVID. […]

• Immediate jeopardy, isolatedF580Aug 20, 2026

  Based on record review, on-call transcript review, and interviews with the staff, the Nurse Practitioner (NP), and Medical Director, the facility failed to report accurate and complete information to the on-call Medical Provider after significant medication errors and failed to report the error to Resident #1's Responsible Party (RP). On 06/29/26, Nurse #1, who was an agency nurse, administered Resident #1's scheduled 9:00 PM medications trazodone (antidepressant), apixaban (anticoagulant), acetaminophen (non-opioid analgesic), buspirone (anxiolytic), and donepezil (cholinesterase inhibitor). Nurse #1 then administered scheduled 9:00 PM medications for Resident #2 who resided in the room next to Resident #1, to Resident #1. […]

• Immediate jeopardy, isolatedF760Aug 20, 2026

  Based on record review, observations, staff, Nurse Practitioner, and Medical Director interviews, the facility failed to have effective systems in place to prevent significant medication errors. On 06/29/26, Nurse #1, who was an agency nurse, administered Resident #1's scheduled 9:00 PM medications trazodone (antidepressant), apixaban (anticoagulant), acetaminophen (non-opioid analgesic), buspirone (anxiolytic), and donepezil (cholinesterase inhibitor). Nurse #1 then administered scheduled 9:00 PM medications for Resident 2 who resided in the room next to Resident #1, to Resident #1. […]

• Actual harm, patternF550Jun 10, 2022

  Based on record review, observations, resident and staff interviews, the facility failed to maintain residents' dignity when there was a delay in answering their call light when toileting/incontinence care was needed, not providing showers/bathing assistance as scheduled and not providing assistance out of bed when requested resulting in residents feeling dirty, mad, isolated and forgotten about. This affected 3 of 14 sampled residents (Residents #46, #84 and #87) reviewed for activities of daily living and dignity. Findings included: 1. Resident #46 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The quarterly Minimum Data Set (MDS) dated [DATE] assessed Resident #46 with intact cognition. […]

• Actual harm, patternF725Jun 10, 2022

  Based on observations, record review, resident and staff interviews the facility failed to maintain sufficient nursing staff to ensure a resident (Resident #84) was not left lying in a soiled brief while waiting for staff to respond to an engaged call light for incontinence care. The facility failed to ensure requests from a resident dependent on staff for transfer (Resident #87) was not left in bed after multiple requests to get out of bed. The facility failed to ensure residents dependent on staff to provide physical assistance with bathing received showers as scheduled (Resident #18, 28, 38, 46, 47, 84, 85, 87). As a result of these failures residents expressed feeling dirty, mad, isolated, and forgotten about. […]